Hello and good afternoon. Welcome to our 145 session. I hope you're looking for the SCI clinical practice guidelines updates. My name is Jeff Johns. I'm the session director and I just have the pleasure of welcoming you and kicking us off. I think you're going to be really excited to hear from the three panelists we have with us today who have worked very hard to bring updated clinical practice guideline information published during the course really of the pandemic and right around that time frame. We thought it'd be important to bring it to this group because many of you may see occasional SCI patients and I thought it was important that you're aware of the most updated clinical practice guidelines particularly in the areas mentioned here of mental health disorders, autonomic dysfunctions, and bone health. And with that I will turn it over to our first speaker and I'll ask each of you to just introduce yourselves if you don't mind. I will say we have nothing to disclose for myself, for Dr. Sabarwal, for Lisa Beck, and you see Dr. Craven's disclosures listed here. Great. Well hello everyone. Thanks for being here. It's a nice day outside so we appreciate you being here. I guess the only disclosure is that all of us have served on the panels that we're going to be talking about but it hopefully doesn't bias our presentation. So I'm going to be talking about management of mental health disorders, substance use disorders, and suicide in adults with spinal cord injury. So this is one of the Consortium for Spinal Cord Medicine guidelines that are administratively supported by the Paralyzed Veterans of America Education and Research Foundation. And how many of you are familiar with these guidelines? Just to show a few of you. So I would say and hopefully you know that these can be accessed and downloaded for free. So please do that. Go to the PVA website www.pva.org and look at their education and research page and you can download guidelines on multiple topics, not just these three that we're going to be talking about today. So the Consortium is really a collection of organizations, both professional and consumer organizations, that are relevant to people with the care of people with spinal cord injury. AAPMNR is one of those. And the Consortium oversees the development of these guidelines and then they have panel members that are assigned to develop these guidelines. It's a pretty long process. The process takes, you know, identifying key questions, you know, doing a literature search. They often have librarians and other sort of researchers doing literature search. Then there's a critical appraisal of the literature and then extracting of the analysis based on analysis of what is relevant and valid and sort of an analysis of the strength of the evidence, the level of the evidence, and then drafting of multiple drafts of the recommendations that are reviewed both by panel members, external experts, and then an extensive field review and legal process. So some of you may have been involved in these in different levels, but it is an involved process. So the one I'm going to be talking about is on mental health disorders and substance use disorders and suicide. And the thing is that I really want to emphasize is this fact about these are clinical practice guidelines. I should probably get my glasses. Rita, thanks for finding these glasses for me. Thank you. These are clinical practice guidelines for health care providers. So the reason I am emphasizing this is that these are not meant just for, given the topic, they're not meant for just mental health professionals. The recognition, the fact is that mental health disorders, substance use, and suicide, and we'll talk about these a little more specifically, are all relatively common in people with spinal cord injury, and they're relatively under-recognized and under-treated and have a big impact on function. And really the entire interprofessional team, including and especially physiatrists who are often leading these teams, have an important role in both identifying and coordinating care, even if they're not the mental health experts in that particular disorder. So the panel itself is listed here. I was the, there were four mental health providers, one nurse, and I was the physician representative, both for the clinical and administrative sort of contributions. I think my one contribution was to really stress having suicide be a separately identified part of it, which it wasn't originally intended to be, just because of the importance of that, both for, you know, we know in general for the U.S. population, but especially for the population of people with spinal cord injuries. So I've already said that these, one of the reasons is that these are more common in people with spinal cord injury, and I'm not going to quote all the figures, but you can see them here in the slide, that many of the topics that are covered in these guidelines are based on the fact that there is evidence, and the level of evidence varies in the, in terms of being SCI-specific from low quality to high quality, but there is evidence that all of these are relatively high prevalence in people with spinal cord injury, with major depressive disorder to be approximately thought to be at 22%, with 27% of people with SCI have significant anxiety, PTSD supposed to be as high as 10%, and then 14% have reported alcohol-related problems, and again, these are selective studies, and you have to look at the studies, and they were looked at in terms of how generalizable these are. 9% of veterans have alcohol use disorders. We know that there's a high prevalence of opioid prescription for people with spinal cord injury, and a high, relatively high percent report misuse of pain medications, and we do know, although these studies vary, that suicide is more common, and suicidal ideation is increased, and we'll talk about some of these a little more specifically as we go along. The other important thing is that there is good evidence that these affect functioning at different levels, whether it's, you know, body structures and functions, whether it is performing activities, or participation, or quality of life, as well as survival, and, and other medical comorbidities are affected by these, and then as I had mentioned, these are often under-recognized and under-treated in people with spinal cord injury. The under-recognition is really related to the fact that, you know, it is, these are occurring often in the context of a catastrophic injury, and there is overlap of symptoms. It's hard to identify, you know, for example, what is depression, what is grief. We'll talk a little bit more about that, and then the under-treatment is related partly to this under-recognition, and partly to the fact that there's so much going on, and so many things that that window of opportunity to identify, and treat, or prevent these in the acute rehab setting, for example, is often not utilized, just because there's so much going on. People don't think about addressing this, or specifically focus on this, and especially with decreased lengths of stay in rehab. There's so much stuff to accomplish, and the team is overwhelmed, the families overwhelmed, the individual with spinal cord injury is often overwhelmed, and these often don't get the priority that they should. So these are the conditions that are covered in the clinical practice guidelines. Major depressive disorder, generalized anxiety and panic disorders, acute stress disorder, and post-traumatic stress disorder, substance use disorder, and suicide. What is not covered in the clinical practice guidelines are things, there was some discussion about addressing things like grief, adaptation to injury, coping, but it was felt at the time, A, that that was too expansive, and B, that some of those sort of concepts are not well-defined, so it was hard to find good evidence for those, not to say that they're not important. There are discussed in the context of these conditions, where they affect these conditions, or need to be differentiated from these conditions, but not as separate sections. These guidelines were in 2020. The first edition, not, this was not the first edition, it was a totally different guideline. In 1998, addressing mental health was only focused on depression, so this was expanded, recognizing that these other conditions are important. So I'm going to talk mostly about major depressive disorder and suicide, maybe a little bit about substance use disorder, where it impacts some of those. The reason I chose not to talk about substance use disorder exclusively is partly because we've got limited time, and partly because, thankfully, a lot of us are getting that education in other ways, and most recently, for example, the eight-hour sort of mandatory CME to maintain your license to get specific sort of education on substance use disorders, and most importantly, and I may stress that a couple of times, is medication-assisted treatment for substance use disorders. There was a recent study in JAMA, just in, I think, March or April of 2023, showing that people with disabilities are much less likely to be referred for medication-assisted treatment for substance use disorders, and so I think it really behooves us to make sure that we are referring, that we are identifying people who may benefit from this and referring them to the appropriate physicians, to the appropriate programs. So there are some general cross-cutting recommendations. So even though I'm not going to talk specifically about, say, anxiety disorders, panic disorders, or post-traumatic stress disorders, actually, you know, anxiety, I'll just say a couple of things about those. Anxiety and panic disorders have specific DSM-5 criteria, the Diagnostic and Statistical Manual by the American Psychological Association. Their fifth edition, which came out in 2013, has, you know, sort of diagnostic criteria for all of these. Anxiety, it's sometimes difficult to distinguish, you know, what is regular, normal worry, but where the, you know, the worry is getting to the point where it's interfering with functioning and it's lasting for six months or more, that's when you make a diagnosis of anxiety disorder. A post-traumatic stress disorder has specific criteria, which are related to intrusive thoughts, whether they are intrusive symptoms, I would say, whether they're intrusive thoughts that the person has hard, is hard to control, they just keep recurring, or intrusive dreams or flashbacks. There's often a dissociation, and then there's, you know, hypervigilance and other sort of reactivity, like startling, those kind of specific factors, and they're all defined in detail in these guidelines. Okay, but these cross-cutting recommendations really are, with some modification, applied to each of these conditions. The first one is to integrate mental health professionals within comprehensive inpatient and outpatient spinal cord injury rehab programs, and part of the reason for this is that there have been studies to show, not so much in SCI, but in other populations. For example, the VA has a primary care mental health integration program that has published research showing that it improves both access to care, the quality of care, and engagement of patients with care. So translating that to the spinal cord rehab setting makes a lot of sense, especially since people with SCI often prefer to get their treatments within the SCI team setting. So the ideal thing that the guidelines recommend is to integrate mental health professionals within comprehensive inpatient and outpatient rehab programs whenever feasible. Because of the prevalence, and because of the under-recognition of these conditions, the cross-cutting recommendation is to routinely screen all individuals for these mental health disorders, and to include not just the current, not just their risk, current risk factors, but also the pre-injury history. Because in many conditions, in fact for most of these conditions, the pre-injury history of having that diagnosis, or of having substance use or alcohol use that increases the risk of those diagnoses, or having other mental health disorders, such as bipolar disorders or schizophrenia, increases the risk of many and or all of these conditions. So it's really important to for people who are suspected to be at risk, or those who screen positive, to then have, you know, more in-depth assessments. And then referring patients who screen positive, both for the diagnostic assessment and for treatment, because we do know that for a lot, many of these conditions, most of these conditions, there are effective treatments, and that using shared decision-making is important, especially in this context, because wherever possible, you know, giving patients at least the education about what the options are, what the expected outcomes are, and to promote sort of self-informed consent and engagement as much as possible. It has been shown to improve both adherence and engagement, so it makes sense. Using valid measures of progress, because these are chronic relapsing conditions mostly, and so to be able to identify risk of relapse, who is, you know, maybe recurrence or residual symptoms is important, as well as as a measure of progress to identify and celebrate gains, which would increase patient engagement. And then, of course, making sure that these are not lost in transitions of care, whether it's from inpatient to outpatient, from an SCI setting to a primary care setting, and to coordinate as much as possible. Sometimes easier said than done, but really important. So I'm going to talk about Jason. Jason was a 28-year-old construction worker who developed a spinal cord injury from a motor vehicle accident, came to the spinal cord injury rehab units after three weeks. He was able to extend his elbows, so he had good triceps, but he had no function in his, no movement in his hands, and he lost sensation from the nipple line downwards, and his neurological level was assessed to be a C7 ASIA impairment scale A. He was admitted for initial rehab, and you can see his MRI there showing C6-7 dislocation. So the question was when and how to screen Jason for depression, and so the clinical guidelines say that all individuals with SCI should be screened for major depression using a brief valid measure. That is good sensitivity. So there are multiple measures available. The one that probably has been most used in SCI and the most published is the Patient Health Questionnaire 9, PHQ-9, and at least sometimes you could just use the first two symptoms of these, the PHQ-2 as a screening measure, and if those are positive, then to do the entire screen, but the two most important things are that there's little interest or pleasure in doing things, which is anhedonia, or that there's a depressed mood, which is, you know, that the person endorses feeling down, depressed, or hopeless most of the days for the majority of the day, and there are other somatic symptoms that we'll talk about a little bit more. The ninth item is related to suicidal ideation, and it's have you ever thought that you'd be better off dead or hurting yourself in some way. So these should all be done. The recommendation is to, you know, again to recognize these early and to catch that window of treatment as early as possible, is to screen people relatively early during their initial hospitalization or rehab stay, and then to repeat that depending on the risk factors, the results of the screen, for example, and then at the first discharge follow-up point. We used to do this at six months post-discharge routinely. We had an unfortunate incident, and those things really stick with you, where someone was discharged, seemed fine during inpatient stay, went to a nursing home because he didn't want to burden his family, and it was his own choice. He could have gone back home and then was just seemed to be doing fine, and then three months later killed himself in the nursing home. So after that, we changed our policy to really do our follow-up assessments sooner, maybe one month or depending on the risk factors, you know, taking the risk factors into consideration, but even six months might be a little late. He was fine and screened negative during the inpatient stay, and then because it is the risk of depression is high, and it's a chronic relapsing thing, to screen for that annually. Three minutes? Oh my goodness, I thought I better, yeah, I'm going to hurry up. Okay, so the question is, is the person depressed or is he having a grief reaction? So we've talked about this, you know, the poor appetite, insomnia, fatigue could be due to medical reasons. If someone has early morning awakening or early morning fatigue, it's more suggestive of depression, but not exclusively so, and if someone's got good appetite but they're losing weight, for example, or they've got fatigue late in the day, more suggestive of a medical condition, but hard to say, and it's really important to consider whether it could be side-effect of medications, other things, regardless if the person is diagnosed to be depressed or not, addressing these other conditions. And then, of course, it's important to, it's not just the mental health professional, but the entire rehab team has a role in supporting patients who are diagnosed to be depressed, whether to, you know, establish, like, easily achievable small but meaningful goals that the person can look at that could encourage hope, whether it is, you know, educating them and the family about the effectiveness of treatment, even for short periods, both pharmacological and non-pharmacological. And, you know, the choice of antidepressant obviously varies. Tricyclic antidepressants, for example, can not only increase drowsiness, they can also have anticholinergic side effects in people with spinal cord injury that affect bladder function, for example. They can, you know, have a high risk of overdose. If the person is at risk for suicide, then you might consider choices that have less likely lethal overdoses, and the SSRIs, SNRIs are generally safer in that regard. Cognitive behavioral therapy is the one non-pharmacological intervention that has had considerable evidence about its effectiveness in depression. So, one year later, Jason had no reported recurrence. His depression had resolved. He came with worsening leg spasms, and he, just the nurse noticed he was saying things like, you know, life really sucks, and she got justifiably concerned about possible suicidal ideation. Previous screens were negative, so she referred that she did the suicide screen. So, the important thing about doing the suicide screen is that people should be comfortable asking in direct, non-judgmental ways about, have you thought about killing yourself, or something, and not asking, like, you aren't thinking of killing yourself, are you, where you're encouraging a no answer. And so, the nurse asked that. It was negative. They did still do a more formal screening, which was thankfully negative, but if someone has suicidal ideation, then the recommended thing is to then screen for suicidal intent or behaviors or plan. And then this is a Columbia suicide severity risk scale that is in the guidelines. And really, something like this should be routinely administered and the patients be referred for more in-depth assessment. I think the important thing, and I realize I'm going to run out of time very soon, is to really recognize the warning signs for suicide. So there are direct warning signs and there are indirect warning signs. So direct warning signs are three things. Suicidal communication, if someone's actually talking about killing themselves or writing a note that I'm going to kill myself. You have to take that seriously regardless of whatever the context is. You know, don't describe it to manipulative behavior or whatever it is. You have to take it seriously every time. Communication for suicide, if someone is, for example, giving away their properties, you know, updating their will without, you know, a good reason suddenly. Or they're seeking access, you know, they'll go and buy a gun, for example. Or, you know, they're hoarding pills, which is some new behavior for them. So those are direct warning signs and they should really flash warning. Warning signs are not the same things as risk factors. Risk factors are chronic kind of things that increase the risk of suicide. Warning factors are the immediate things that increase immediate risk of suicide. Suicide is an impulsive kind of behavior. So if you can detect and prevent these signs, you can prevent suicide. It's not that if someone says, I want to kill myself, that they will kill themselves. It is an impulsive kind of behavior. These are these indirect signs and they're listed here and I'm not going to go into them in detail, but those are also important to recognize. And then to stratify suicide risk based on severity and temporality, the biggest thing is if someone is at high acute risk, that they have an intent or a plan to kill themselves, and it is, you cannot establish that they can independently maintain safety without external support, they should be hospitalized. Of course, it's difficult to do that in a mental health unit because of bowel, bladder, all the other issues, and being vulnerable to attacks in a, in a psychiatric unit. So typically it's a one-to-one sitter in a hospitalization. And then, you know, you stratify based on other kind of things. Really important to treat these comorbid conditions, including pain and substance use disorders. Everyone should be familiar with this. When the guidelines were written, it used to be 1-800-273-TALK was the suicide prevention crisis line. Now it is 988. And so patients should know about this. Their caregivers should know about this. And then we actually put gun locks in our clinics. We put them, we have veterans with, we just put a basket of gun locks and without a judgmental thing, and those are often gone. You know, people just take the gun locks. So even if someone has an unloaded or a locked gun, that dramatically reduces the risk for suicide. Fifty percent of suicides in people with spinal cord injury are due to gunshot wounds, followed by lethal, you know, about 16 percent overdose in one study, and then, you know, other things like cutting or hanging or drowning. And this part where I'm going to end with on the positive fact that we often underestimate the personal and environmental protective factors, whether it's a recreation therapist, whether it's adaptive sports, whether it's engaging in social connections, peer programs. But a lot of patients say that they really, that was life-changing, and it does affect this. So I am going to end there, and thank you. Good afternoon, thanks, Sunil, for that great talk. I'm Lisa Beckman, clinical nurse specialist provider at Mayo Clinic, and I was part of the task force regarding the autonomic dysreflexia, dysfunction, both clinical practice guidelines as well as the consumer guidelines. A lot of mine is going to be show and tell, but actually give you an update on where we've gone with the guideline. The original guideline started, I believe, was published in 2000. This is our most recent task force member on the right. We started this group in 2019, and it was actually published in 2020. So it does, as Sunil alluded to, these do take a long time to go from thought to publication. So we had a group of experts on this panel that was really fantastic to work with. So lots of updates to the guideline, and that's exactly what I'm going to highlight are just some of the updates. One of the biggest updates is that of our algorithm. So the algorithm has been updated, a quick pathway for you to determine the treatment and the follow-through of the patient that you may suspect is experiencing autonomic dysreflexia. I do have one little block highlighted here that is a big change in our guideline, and this actually comes from a research project from my colleagues and friends, Dr. Todd Lenzemeier and Ryan Selensky's paper from 2019 regarding intravascular lidocaine, and their paper really encourages us to use the lidocaine gel, but to make sure it's dwelled at least four to six minutes. In our previous guidelines, I believe we had it from two to three minutes, so a little longer dwelling time actually seems to be the key when we're doing invasive procedures such as removing cath, you know, putting new catheters in, doing systemic or cystoscopies, follow management guides for that. Some other additions to our guideline, and one of the things I really like is our table of medications used for autonomic dysreflexia, which gives you the drug options that can be utilized. I know at the time when we were developing this guideline, nitroglycerin and ointment was not available in Canada, so that was kind of a hiccup in making sure we had options no matter where people were on fact acting hypertensives, and I love, you know, that we have the precautions and everything right there for you to search through and utilize. Not only did we update with this table, but we updated other topics, and so it kind of hit some of the highlights in these topics. Regarding sexual activity, we have a short chapter on how to manage AD with those engaged in sexual activity, certainly those with T6 and above are at risk of autonomic dysreflexia, and the intensity of stimulation is really going to be reflective of the intensity of autonomic dysreflexia. In fact, ejaculation is one of the most potential triggers of AD, so we do have to make sure we as providers are aware of this, and we're also educating our patients and our consumers regarding this risk. Again, a second orgasm is going to cause higher incidence of AD. We do encourage our consumers to have an at-home BP monitor and really talking with their provider regarding their signs and symptoms of AD during intercourse, and possibly having a prophylactic type medication at hand. We have a topic on AD in pregnancy and through postpartum. One of the biggest, and I think really important thing is to have a multidisciplinary team for our women that are considering pregnancy, especially those above T10, I'm sorry, T6 and above at the risk of dysreflexia. We have to help them understand, you know, if they're going full term, hopefully for a natural delivery, is epidural an option for anesthesia? And we have to help our patients and the multidisciplinary team, the OB team and the anesthesia team, understand what the difference is between autonomic dysreflexia and preeclampsia. Certainly with autonomic dysreflexia, we're going to see that blood pressure going up during contractures and abate when the contracture is gone, versus preeclampsia, we'll see the high blood pressures continue. And again, even past delivery, we still have to educate our moms regarding autonomic dysreflexia related to breastfeeding, breast engorgement, and mastitis. Urologic studies. We do a lot of invasive procedures in our urology, but definitely needed to follow the health of our patients with spinal cord injury and their neurodegenerative bladder. Urodynamic studies is a great example. We're distending the bladder, and certainly this can cause AD. Unfortunately, we can't do these tests and procedures with patients sitting up as well. I know there's some new chairs in the urodynamic suites that are being used a little bit. But sometimes we have to stop the procedure because of dysreflexia. So there are some things we do encourage is take measures before the urodynamic test. If they're on anticholinergics, continue with the anticholinergic even 24 hours prior to the test. Continue those all the way through. If they have a bowel program, it would be really nice to have an empty bowel that day of their urodynamic study. If they have a urinary tract infection, usually we won't do studies per se. So we want to make sure that's treated. We want to hold any medications that may elevate blood pressure, like midadrenal florina. Certainly hold their PDE5 inhibitors. Again, the lidocaine jelly can be used before instrumentation. So that dwell time again, four to six minutes. And if you have to cancel the procedure because of their AD, it just needs to be scheduled. So you'll have to monitor the patient during that episode, of course. Another new addition to our guideline is that of boosting. And now we're coming up to the 2024 Paralympics. Boosting has really become a topic since 1994 or so, now 30 years, that the IPC deemed boosting to be illegal. I mean, this is intentional induction of AD, really to enhance their performance, okay? So we've had athletes that will induce their AD by clamping their catheter, putting a leg strapped too tight, breaking their toe, which does not sound fun or helpful, or even sitting on the scrotum. You know, the hard part with this is it's really hard to monitor. So this can be induced even during competition. So it's hard to monitor when the athlete is engaged in their competition, if they are boosting per se. The risk is we really don't know the lifelong health risk of this boosting. So it is really our job as providers to help them understand the risk of AD and these boosting type episodes. You know, we know the risk of AD of intracranial hemorrhage and stroke, potentially hydrodendrophosis. So we have to be aware of that and really help our patients understand that. Unfortunately, or fortunately, the IPC did drop down their systolic blood pressure from 180 millimeters mercury to 160. In the guideline, we do suggest starting to treat for AD at 150 millimeters mercury systolic. So another addition to our guidelines is that of autonomic dysfunctions, which I think has been a really nice addition, and I utilize these quite a bit in my practice. Orthostatic hypertension, we definitely have some guidelines or some guidance of how to accurately diagnose orthostatic challenges and use these challenges. Prevention of orthostatic hypertension, there's really low evidence in the guides, but it gives you some opportunities to try. Pharmacological, we have the Midodrine and the Florin F as an option. Non-pharmacological, we have abdominal binders, FES, reclining position, compression stockings. Thermal regulation has been a nice hit or a nice addition to our guidelines as well. Additionally, there's medications that can disrupt thermal regulation, either hypo or hyper. And these are common medications we use with our persons with spinal cord injury. And yes, this was probably taken in Minnesota, this picture. This is how it is. Hypothermia, again, I am in Minnesota, so we definitely have cold temperatures, and so we have to be aware of our patients that are exposed in the cold weather. Certainly, I encourage them if their nose is cold, their toes are cold, and so is their body, although they may not sense it. So be aware of signs and symptoms. And when checking a temperature, the rectal temperature is your most accurate temperature, considering hypothermia, persons with spinal cord injury, a skin temperature, the new devices are not as reliable or accurate. Management, we encourage insulating, insulation clothing, blankets, warm, humidified air. Heating devices, I'm very nervous about heating devices or sitting by a heater or a fireplace. I've seen some horrendous burns that people have occurred, secondary by being by heat sources. So be cautioned regarding that and avoiding any alcohol intake that would cause basal dilation and heat loss. Hyperthermia, and yes, we do get that in Minnesota as well, we get nice hot weather. Hyperthermia is a little bit trickier. It's kind of a diagnosis of exclusion, are they infected? Those folks early on in acute SCI, do they have what's called neurogenic quad fever? So it really does require a complete evaluation and workup. Our SCI athletes have a difficult time acclimating to the warm environments, so that might also affect their performance. So with hyperthermia, monitoring for signs and symptoms, certainly when a hospital room is hot and patients are packaged and we're positioning them ever so purposely to avoid pressure injury, but we have them all tucked in with pillows, certainly they can get warm and take on an environmental temperature. Hot days, sitting outside, sitting out in the car, just really reminding patients to be aware of what their environment is like. So removing them from hot places, drinking cold liquids, using tap water, and again teaching preventative hyperthermia, these are really important factors. I go over with my patients in Minnesota because we see both extremes of hot and cold temperatures. And then hyperhidrosis, this too I've utilized in my practice using this little chapter. Again it's not high level research or practice guidelines, but it gives you some opportunities on how you can help manage hyperhidrosis. I mean, this is excessive sweating that is annoying to the patient. It's above and below their level of injury. First thing you do need to look, it's a lot of times it is associated with autonomic dysreflexia, so you have to try and rule that out. It is related to triggers, so again, as with dysreflexia, you're looking at bowel and bladder issues, stone, skin issues, how they sit in their chair. And then again, as I said, there's some good opportunities as to what medications you might want to try if this is an ongoing problem for your patient. And then the last part here is really consumer guides, and kind of a show and tell for you. So we had consumer guidelines related to autonomic dysreflexia in the past, and it's the one you see on the left, What You Should Know. Our biggest addition was a second pamphlet, and it's really more about autonomic dysreflexia, so adding in the chapters regarding sexual health, neurologic procedures and such, as well as the other autonomic dysfunctions. So with these guides, we had a few of our original clinical panel on board, but we had a robust consumer panel that was very helpful in making sure we had the right language, the right concerns, and even helped us update the photos that go on the guides. The revisions to the autonomic dysreflexia guide, one of the biggest things we did is right up front, you open the booklet, and it's really a quick summary of what are you looking for, what are the signs and symptoms, if anything looks like dysreflexia, here's the next step. The coolest thing, and thank you, COVID, now we have a QR code on everything that the patient can get home to your emergency room, bring their consumer guide, and the QR code will bring up the clinical practice guideline. We also have a new format, more of a table form of if you're looking at the different clauses and how to prevent and ameliorate those. We also have several pages of a diary, so people can kind of track what might be going on, why are they becoming so dysreflexic, and what are their symptoms, what were they doing when this happened. And our consumer panel thought, you know, dang, there should be an app for that, which potentially we'll get there. The second pamphlet is that the autonomic dysreflexia and dysfunction, so the additional ones. As I mentioned, as you see, we added the orthostatic hypotension, hyperhidrosis, and thermoregulation. Here too, we have quick access to the guidelines, both the autonomic guideline for consumers as well as a clinical practice guideline. We have quick tarot charts regarding the dysfunctions that I spoke to earlier. And then finally, the updated wallet card. And I wish I could say I had a bunch here. Unfortunately, they're kind of on back order. So if you're interested in obtaining the wallet cards to contact Paralyzed Veterans Organization, Cheryl Vines has been our contact and can help you route through the right person to get some of these cards for your practice. So I thank you for your time. That's a good way to start. Good afternoon. My name is Dr. Kathy Craven. I am a professor in the Department of Medicine at the University of Toronto and the Cope Family Chair in Spinal Cord Injury Health Systems Innovation. And I'm going to talk to you today about the Bone Health and Osteoporosis Management Guidelines. And I want to begin by acknowledging the wonderful panel that we had that participated in the development of these guidelines. And I particularly wanted to acknowledge Dr. Laura Carbone and Dr. Leslie Morse, who led the development of related publications, Leslie on the ISCD Bone Density Testing Statement and Dr. Laura Carbone on the OTA Delphi Consensus Management of Fractures. And I would encourage you, for reading beyond today, to actually read all three. And we did work very hard to get these documents to align with one another and be consistent. I did want to review with you, in the CPG is a sort of flow diagram that is a little bit hard to see, but it's intended to show you how the sections of the CPG relate to one another. The CPG was designed for members of an interprofessional team. So of course, if you're a physiotherapist, you might be interested in the rehab interventions or your dietician may be interested in the recommendations around calcium and vitamin D. You're a radiologist about bone density testing. You as a physiatrist in the medical history laboratory screening and fracture risk assessment. And our recommendation is that you work through this guideline, each of the sections, early after spinal cord injury or disease onset or immediately after a fracture. The guideline is designed so that each section stands alone. You can look at just read one chapter and be done, but ideally you would look at all of them over time. But if you want to just give one section to members of your team to review, it will stand up for use in that manner. This was a conventional systematic review that was supported by the SCIRE project. So I just want to give a shout out to Janice Eng in Canada, who helped to lead the systematic search. From our many over 5,000 articles, we did come up to 124 studies with 64 recommendations related to bone health, spinal cord injury, and topics of inquiry, including assessment, prevalence, treatment, and fracture. And I do want to acknowledge right now that there is no paper that looks at fracture risk reduction. All of the papers look at interim improvements in bone marrow density as being a surrogate outcome for fracture risk reduction. In Appendix E of the guidelines, there is a Cochrane Risk of Bias Diagrams that allow you to assess the internal validity of studies. And you'll see in the appendices these four observational studies and RCTs for both drug and rehab interventions. So if you want to go in, and particularly for budding scientists in the crowd, you can see where we are falling down in the structure of clinical trials. And so you can look and you'll see overall, if a study has a high risk of bias, it will have those red dots. And if we're unable to score because criteria isn't reported, yellow. And that's really a target for journal editors to make sure that we're reporting all of those criteria. Throughout the CPG, we do have effect size diagrams. And just a reminder for those that we have the zero no effect line in the middle here. And then pooled point estimates are the squares with the 95% confidence intervals with studies which favor treatment appearing to the right of the no effect line. And when there's a diamond, there's a pooled estimate. And in this guideline, there are very few pooled estimates where studies have used similar methodology. So it's important that we maybe start to work together to do some multicenter intervention studies. And of course, HEDGES-G was used to correct for potential biases related to small sample size because most of the trials had small sample sizes. We use the regular agree rating scale. But I just wanted to point out the use of language that when there was a, for example, a 1B recommendation, which is common throughout the guideline, this is where we see that the benefits of an intervention clearly outweigh the risk. And that it's appropriate for most patients in most circumstances, you will see the wording before the recommendation, we recommend. And if there is weaker evidence, so example 2B, which is quite common, where the best action may differ depending on the patient's circumstances or societal values, you'll see the terms. We suggest that we'll tell you about that it's weak recommendation with moderate quality evidence. And throughout the guideline, there are a lot of 2D recommendations. So weak recommendation, very low quality evidence, and you'll see the wording one may consider. So if you're thinking about how to make practice change after we review all of this today, maybe focus in on those that say we recommend. Throughout the guidelines, we have some clinical considerations below each of the recommendations. So in this case, this is an example of we recommend that premenopausal women with amenorrhea have laboratory screening. That includes screening for prolactinomas, so including FSH, LH, and estradiol levels. And then we have some very clinical sort of, wait a minute, make sure you're not doing the wrong thing here, that comes in the clinical considerations both throughout the CPG. So please take the time to pay attention to those. The CPG in its current form and available on the website like the other guidelines you've heard about today is intended for a clinician audience, but we've also created, instead of the typical patient version of the guideline, we've actually created a podcast series that is directed at sharing the content of the guidelines with patients. And so we've structured the podcast series. There are nine podcasts, each which correspond to the chapters in the Bone Health and Osteoporosis Management CPG. And associated with that podcast is a one-page handout that reminds the patient what is in there. And we've had a number of people with lived experience evaluate them and say that the use of the podcast and the handout does help them know what to do and how to advocate for their own bone health. So this is available on www.scifragments.ca and I'll show you the website at the end. And I would encourage that you take the time to visit it. And if you've got an hour, you're out for a jog, you're doing the dishes, you can review the whole CPG quickly at a patient level, which for many people who don't practice spinal cord injury all the time is more than sufficient to take away the key messages. The podcasts were developed by people of lived experience. So they reviewed the content of the CPG and decide what were the key questions to be asked. During the podcast, people with lived experience act as hosts in the podcast. And panel members from the CPG panel are actually the hosts for each CPG and are talking about the chapters in which they materially contributed to the CPG itself. Following the sort of identification of what content was relevant, we did some orientation of the host to the process and some sound editing. And then we sent these out for review by people with lived experience. And then we created handouts and then sort of did an iterative review with stakeholders about whether our documents were appropriate, consistent with the CPG and the key messages in the podcast. And those handouts, those educational action tools that are on the website have undergone about 27 revisions. So they're in decent shape. So I wanted to give you a case that's a common scenario you would find in your clinical practice. We have a lot of J names today. So our case is Jordan, who is a 48-year-old male with T8 asia paraplegia, secondary to a motor vehicle accident three years ago. And prior to his injury, he enjoyed playing pickup basketball once a week and rode his bike three times a week. And Jordan wants to know, does he need a bone density test and what he can do to prevent osteoporosis? And he prefers to avoid drug therapy because he's been experiencing some stomach problems since the onset of his injury. Does this scenario ring true to many people? Would you have encountered this before? Anyone? Okay, so I just thought we'd go through this. So the guidelines suggest that after doing a history with the patient of looking at their comorbid medical conditions, that as soon as possible after establishing care, that we would do a lab assessment. We also are recommending that the lab assessment be done after a new fracture, or if there's been a significant change in the person's medical condition. So that's just thinking about lab assessment over the lifetime. And these are the minimum requirements that we're recommending you do laboratory screening. In my own practice, when we do this routine laboratory screening, one in three patients, we find a secondary cause of osteoporosis that is amenable to therapy. And of course, you need to remember those patients who present with a vertebral fracture as the cause of their spinal cord injury, that you need to make sure that you have checked for myeloma and that you've looked for causes of cancer that may have been missed in addition to what is on the screen. And I really encourage you to make sure that for premenopausal women, that you're doing that screening, and as well as men screening for hypogonadism. And as we just talked about, anyone over the age of 50 with a vertebral compression fracture, you wanna make sure you've done that protein electrophoresis screening. And then there's a number of other tests in here. And if you're going to manage a patient with spinal cord injury and CKD5, you really need a nephrologist on your team. So you shouldn't be trying to do that independently as yourself. You should be recruiting a colleague to help you. Bone density testing. How many people have access to bone density testing in their center? So you should be able to measure the lumbar spine and the hip, correct? What we're trying to move the whole field to is measuring distal femur and proximal tibia bone marrow density. So we want you to change the sites that you're measuring. And we want funders to change what they're going to fund to be measured, which is another separate battle. And we want you to know the least significant change at your site and how to help your patient estimate fracture risk. So the ISCD positions which we've endorsed in the PVA bone health guidelines are recommending that all adults with spinal cord injury resulting in permanent impairment undergo a bone marrow density scan of the hip, distal femur and proximal tibia as soon as they are medically stable. So that is likely going to be in your rehab setting. Or for some, it may be if they move quickly onto a SNF, it might be when they're in a skilled nursing facility. And we have shown in our literature review that you can use bone marrow density of the total hip, distal femur and proximal tibia to diagnose osteoporosis, presence or absence of disease, to predict lower extremity fracture risk as low, moderate or high, and monitor this response to therapy where normative data are available. If you are interested, I have posted our knee acquisition protocol and our normative data on the University Health Network KITE website and I'm happy to share it with you if you're interested. And then we're asking that people have bone marrow density scanning at one to two year intervals thereafter. So when you come for follow-up, you need to know how much change would you expect versus what is the least significant change of your densitometer. In the first year, there's dramatic declines in bone density. They're very predictable for those who are motor-complete. For those who are motor-incomplete, it's not as predictable and it's really important that you actually measure, but you need to know if the change in bone density is greater than the least significant change of your densitometer. Bone changes slowly. It takes multiple cycles of bone turnover to get measurable changes in bone marrow density. And we would like you to assess a patient's fracture risk annually. On the screen here, you'll see two risk factors highlighted in red. This is what I call the big two. So if your patient has low hip or knee region bone marrow density below the fracture threshold and they've had prior fracture, these are the people with the highest risk of fracture. You don't need to do any special test. You know this right away. These are the people with more than a 20% risk of fracture. And then these other risk factors you can just do through medical history. History of hip fracture in the last year. Family history of fracture. So that could be wrist, vertebra, or hip. Alcohol intake of greater than five servings per day. Paraplegia. Motor-complete injury. Duration of more than 10 years. And one that's really hard, early post-injury, routine use of benzos, anticonvulsants, and opioids. So those are modifiable risk factors you can work on with your patients over time. As they leave the rehab center, you can try to work to wean those off over time. Published today in Topics in Spinal Cord Injury Rehab, we have a new model that's a very preliminary model for fracture risk prediction that's coming from a small data set from a longitudinal study in Toronto. And I am working with colleagues to validate that with VA data. So hopefully we'll have a validated fracture risk tool for you in about a year. Vitamin D and calcium. So we're recommending that everybody gets an opportunity to have their 25-hydroxy D serum level measured. And this should be done likely when patients are coming to rehab initially, and if they have any big changes in their medications that are metabolized by the liver. And we want to make sure for those who we find are vitamin D deficient that you recheck their level after giving them repletion therapy for three months. And in the Bone Health CPG, there's actually a flow diagram of how much to give people based on their levels. Secondary hyperparathyroidism is very common in the spinal cord injury population in the presence of vitamin D deficiency. So it's very important that you make sure before you start any bone treatments, you've done that laboratory screening, and you've confirmed that the vitamin D level is therapeutic, and that has a whole other host of positive benefits for the patient and their health. And when we look at calcium intake, it is really important that you try to move your patients to having dietary calcium, meaning calcium in food, and not in supplements. When you take supplements, there's quite a dramatic rise in your serum calcium, which does increase the risk of patients developing bladder or kidney stones. And for those patients who do have established calcium oxalate stones, or known hypercalciuria, we would probably recommend that you reduce their intake to 750 milligrams per day, not the 1,000 milligrams per day. And if you have people who are just learning to establish their neurogenic bowel, they will be miserable if you start them on a calcium supplement. So I'd encourage you to really work hard with your dieticians and your patients to get that dietary calcium intake through food, and in the guideline, there's a very nice calcium assessment tool that is a great way to remind people all the different ways that they can optimize their dietary calcium intake. The ISCD fourth official position in the paper that I talked about, published by Leslie Morse, talks about there's really no bone density threshold below which we should say weight-bearing activity is absolutely contraindicated, but we are suggesting that you have a meaningful conversation with your patient about their fracture risk factors before they engage in weight-bearing activity. So you may have therapists coming to you now and asking, can we look at this patient's fracture risk before they do body weight support treadmill training or before they start using an exoskeleton? How many people have had to deal with that? And in the setting of chronic spinal cord injury, we'd really recommend that you screen for occult foot, heel, and ankle fractures prior to intervention, because in many of the clinical trials, when this is done as a inclusion-exclusion criteria, many occult fractures are discovered, which then places the patient at higher risk of fracture. The people you probably want to think about not encouraging them to do weight-bearing activity are the people who have significant deformity that is preventing them from loading the bones normally, because with spinal cord injury, we get thinning of the cortices, reductions in trabecular volume and number, and the patient is much more susceptible to torsional stress. So nobody should be prevented, but they need to understand their risk when you're consenting them. When you're doing the risk factor assessment, you need to look at what risk factors are modifiable and which ones are not. So if we look at Jordan, our case, he has traumatic spinal cord injury, motor complete SCI, he hasn't had it for very long, but he's taking opioids for pain. That opioid use is a modifiable risk factor that you could go after. When you look at the exercise and drug recommendations throughout the CPG, we use two terms that I want to make sure you really understand. Prevention is defined as really when we're looking at intervening before bone marrow density and fracture risk is established. So that's the conventional young person who is injured in a motor vehicle accident or from a fall who's presenting with normal bone marrow density. But don't forget there's lots of patients with non-traumatic spinal cord injury now who may be presenting with pre-morbid osteoporosis. Now they've got their spinal cord injury. And that's group that would fall into the treatment category. Treatment is where it's really easy. Everybody knows the person has low bone marrow density and high fracture risk. And everybody feels confident about providing therapy in the setting of low BMD and high fracture risk. And where patients and providers hesitate is in the setting of prevention of trying to turn off the bone loss because you're kind of committing somebody to a long-term intervention. So in the next part of this presentation, I'm talking about prevention, not treatment, because I think it's probably one of the more controversial areas. And the treatment literature is nicely highlighted in the guideline. Passive standing. How many people encourage patients to do passive standing or have passive standers in their center? So there is evidence. Note the wording, one may consider. So it's weak evidence from one study showing that if you do passive standing for one hour, five times per week for two years, you can actually reduce the amount of bone that is resorbed at the hip and knee regions. So with a highly motivated client and resource, you may be able to turn off some of that bone loss, but that only is sustained as long as they continue to do the passive standing. And so that's a really important part. And then the other thing that many people are talking about is FES and NMES, and that we want to make sure that we're doing, in general, muscle-activated and load-bearing rehab for a duration of one year. And throughout the CPG, there's a very important discussion of loading and the need to measure loading that I hope the research community will listen to and start to think about how to implement. But we've got some very specific, there's hundreds of FES and NMES protocols, but only a very small number that have actually shown improvements in bone. So you can do FES and you will get functional improvements. You will see changes sometimes in muscle and in muscle density, and you'll see improvements in cardiovascular function, but to change bone, we're asking you to use these specific parameters of a pulse duration of 200 microseconds or higher frequencies of 20 to 33 hertz and amplitudes of 140 milliamps, where, and we've provided operational definitions of FES when you're doing a functional activity, such as cycling or rowing, which might be appealing to Jordan, or NMES where you're doing contraction against some resistance, such as during passive standing or loading of the limbs. And of course, this is all directed at lower extremity FES. You do not want to use these parameters in upper extremity in a quad. And then in terms of drug therapy recommendations, we have recommendations that clinicians and individuals use shared decision-making that accounts for the patient's values, preferences, and their medical comorbidities, and that we recommend that those people who have motor-complete injuries that you can very reliably predict are gonna be primary wheelchair users. These are the people you should be offering drug therapy because they will have the profound bone loss in the first year, and the lifetime increased risk of fragility fracture. And for those with incomplete injuries, it's a little bit more of a discussion. We are recommending that you offer bisphosphonates, particularly alendronate and zoledronic acid, or denosumab, all of which are anti-resorptive therapy with different routes of administration, whether that is oral, intravenous, or subcutaneous. Just the one proviso, I know that many people are familiar with the common adverse effects of oral bisphosphonates in terms of GI side effects and osteonecrosis of the jaw, atrial fibrillation, but there's also a new sort of body of literature with the nitrogen-containing bisphosphonates looking at inflammatory changes in the eye that you need to make sure you're consenting people with. And with denosumab, there's some new literature showing actually reductions in breast cancer risk in young premenopausal women. So, yep. Okay, so in terms of, you know, you really need to be familiar with these and be able to talk your patients through it in terms of risk of atypical femoral fracture and ONJ. If your patients are going for dental work, their gums are gonna be open, you're gonna suspend the therapy. What's new in this guideline is a whole new section on fracture recognition and management. And if a patient's presenting to you with a swollen red leg, we want you to think of, is this HO, cellulitis, fracture, tissue injury, or venous thromboembolism? And if you remember nothing today, we wanna make sure that our spinal cord injury patients with long bone fractures are actually undergoing an orthopedic consult. And that as soon as a person has had an established fragility fracture, we need to recognize them as having high fracture risk and then revisit this whole paradigm that's shown on the right. And there are now recommendations for EVTE prophylaxis after fracture, and that's using low molecular weight heparin or DOAC that you'll be very familiar with. So not very different, but we do have very specific thresholds there in the guidelines. So just in terms of coming back to our case, you'd wanna screen for secondary causes of osteoporosis, do a DEXA of the hip and knee region at baseline, talk to your patient about dietary calcium intake of 1,000 milligrams per day, offer them vitamin D, 2,000 international units if they have slightly low serum 25 hydroxy D level. You could talk to them about passive standing and alendronate. And in the event that they deteriorate and have a fracture down the road, which is usually about eight years later, that they get that orthopedic consult for definitive fracture management. And I did wanna also say a call out and a thanks to the members of our Bare Bones podcast production team, and there's the website here at the bottom, www.scifragments.com. And here's quick access to the bone health and mental health substance use disorders, CPGs. Thanks for your time. Thank you. Cathy, I'm sorry if I missed it, but did you say whether or not the bone health has recommendations for treatment of HO as well as fracture risk, or is that a separate? It's a whole separate beast. Sorry, the question was whether the bone health guidelines cover heterotopic ossification. The answer is no. So that's a whole separate outside topic. And if you want my answer, I normally give a drug like Mobicox and Coenzyme Q10 to reduce the inflammatory component in patients who do have recognized evolving HO. That's Craven's opinion and not an evidence-based answer. So extending on the Craven opinion, when you're dealing with both low bone density and heterotopic ossification, do you have any recommendations prior to prioritizing treating one versus the other because they're on different timelines, or exactly how those things are interacting when it comes to minimal metabolism? Well, you really need to go after the HO first, because if it restricts the patient's hip or knee range of motion, it will change their loading of bone over their lifetime. And there is good evidence around the role in select cases for radiotherapy or surgical debridement, provided the HO is not wrapped around a vascular structure. So in terms of priority, I would pick the HO first, because if it progresses to ankylosis, it's got long-term ramifications for the person's seating, their dressing, and many other things. So I'm not sure everyone else would answer the same way, but that would be my answers, that we want to maintain that range of motion of the hip and knee region as much as possible. And the bone changes will happen, but at least as you maintain range of motion, you'll be loading bone more normally and being able to take advantage of what structural integrity is there in the cortex that's thinner than baseline. Thanks. Sorry, Keith. Hello. I have two questions, both about chronic spinal cord injury. One, just a quick one about how often would you recommend getting a new DEXA scan of the patients? And also, if you have someone who is experiencing AD most likely due to something chronic, like a wound, where you can't immediately address it, where you've ruled out other things, what are your first recommendations about how to treat that until that issue has resolved? So let me make sure you've asked two questions. One is about access to DEXA scan, and the other is about management of AD in a patient with a non-healing wound? Yes, so the DEXA scan was just how often would you recommend getting repeat scans on a chronic spinal cord? And the second is, if someone has AD due to something like a wound or something that you can't immediately treat, or it's taking time to heal, but the AD is persisting, and you've ruled out other causes, what medications or what is your general approach to managing that? OK, so in the first year, two years after injury, particularly if the person is motor complete, so AIS-A or B, there's dramatic declines in bone marrow density, and I would say annually in the first two years. And then you can probably extend it to 18 to 24 months thereafter. That is not a consensus opinion, but it's close to what the guideline is actually saying. And that's looking at a number of the longitudinal studies that map very elegantly the changes in bone marrow density and the pattern in which they occur. And I'll turn it over to Lisa to answer the AD question. Yeah, thanks. That's an interesting question regarding a wound. And they are hard to treat, and AD is usually an acute scenario. And I dabble enough in wound care to help you a little bit with this. Certainly, we want to get the wound debrided and cleaned and offloaded, because sitting on an irritated, inflamed area will certainly cause AD. So it's important not only just to manage the AD, but also certainly looking at your wound, looking with your wound care therapist, at management, your seating clinic therapist, or what equipment to offload that they best can. Santal is a nice opportunity. It does reduce some of the inflammation, some of the pain that people experience, and silvers do. So there's some mechanism to reduce that component, those triggers. So it's really reducing the trigger to manage it. I just want to say if the patient has a stage 4 wound that is down to bone, then you can assume they likely have osteomyelitis, and that may be what's triggering the AD. And so sometimes, if you've diagnosed the osteomyelitis and started treatment with both antibiotics or even just an NSAID, you will sometimes reduce that AD if that's the cause. I don't see any questions from our online participants. We have about one minute left, so I think we have time for one more question, and then maybe we can take some other questions afterwards. Really quick, just a comment on the slide. The SCI Fragments website is .ca, not .com. And then really quick, kind of a follow-up AD question. Recently, it was referred to a woman who has sweating during pregnancy. And the question is, yeah, is that AD versus not? How do you differentiate that? Is that based on blood pressure or so forth? She intends to have future children, so would like some management. And then how would you manage that if you decided, yeah, it is AD. Then in a pregnant woman, what kinds of things can you take? Because it's a nine-month pregnancy, obviously. So you can't just get rid of the trigger like we would with the bladder or something. Thank you for that question. Again, it's really, we know what the pregnancy is causing it. And then the medications that I did show to help treat hyperhidrosis are certainly those that have iatrogenic probabilities to our pregnant mom. So we have to be careful with those medications to reduce the sweating. So if it's just purely hyperhidrosis versus AD. So definitely the biggest thing you want to do with your mom is monitor her blood pressure and make sure we're not having higher blood pressures that require antihypertensives if we need to. Also during pregnancy, we have to be careful that we don't cause problems to that fetus too with the high blood pressure. So it's really a balancing game working with the OB team hand-in-hand. We've worked with our OB team. I have been clinical in the past, not only the OB team, but also anesthesia to help monitor. Because it's a tricky question. And there's not a lot of evidence out there to help us and to guide us. Thank you for the question. Yes, I love it. I have seen a number of women with hyperhidrosis due to hydronephrosis during pregnancy. And so it does require that ultrasound evaluation of the kidneys to see what's actually happening. And I have seen one woman with hyperhidrosis with preeclampsia. So just to complicate things further. And one who was developing a syrinx with hyperhidrosis. But you could tell that by the distribution of the hyperhidrosis. So important to really distinguish in history if it's regional or diffuse hyperhidrosis. And that might help you figure out whether it's cord-related as opposed to pregnancy-related. Great. Well, again, I thank you for your time and attention and your engagement. Sunil, Lisa, and Kathy, thank you for being here and updating us about these clinical practice guidelines. I do encourage you to visit the websites that were mentioned, particularly the pva.org, where you can access all of these clinical practice guidelines, both for health care professionals and consumers. And with that, we will wrap up. Thank you very much.

SCI clinical practice guidelines

mental health disorders

autonomic dysfunctions

bone health

spinal cord injury patients

under-recognized conditions

interprofessional care teams

routine screening

valid measures

comorbid conditions

education and communication