Rutgers New Jersey Medical School

Objectives: In parallel with the opioid epidemic, there has been a resurgence in abuse, medical complications, and deaths related to amphetamines. The opioid epidemic began with increasing rates of prescription products that evolved overtime to include heroin and more recently, fentanyl analogues. Current trends in amphetamine prescriptions are less well described. We sought to determine if there has been a change in amphetamine prescriptions given at discharge in U.S. emergency departments (EDs) in recent years. Methods: We conducted a retrospective review of data provided by the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2012 to 2019. We computed total number of visits that were given amphetamine prescriptions (amphetamine salts, methylphenidate derivatives, and dexmethylphenidate) at discharge for each year. We computed the total number and rate of visits (of all ED visits) that had both amphetamines and opioids prescribed at discharge over the years. We computed data normality using Shapiro Wilke's test and used descriptive statistics such as mean to describe the data distribution as applicable. We used spearman's rho (SR) or pearson's correlation (PC) as applicable to describe trends in data. All p-values were one-tailed and were reported at a 0.05 significance level. All analyses were conducted in IBM SPSS version 28. Results/findings: From 2012 to 2019, there were an estimated 817,895 ED visits where an amphetamine prescription was given at discharge, with an overall strong increase in rate over time (SR = 0.71, p = 0.02). At the beginning of the study period (2012) there were 83,503 (0.06%) visits and in 2019 there were 186,539 (0.12%) visits (123% absolute increase). On average, there were 102,237 (SD: 52,725) visits with discharge amphetamine prescriptions per year. There was a strong, linear increase in number of visits that involved a discharge amphetamine salt prescription (PC = 0.92, p = 0.001). In 2012, there were a total of 23,676 visits and in 2019, a total of 124,773 visits (427% increase). There was no trend in visits where both an amphetamine and opioid were prescribed (PC: 0.61, p = 0.06). Conclusion: There have been increases in discharge prescriptions for amphetamines in the ED over time. This was largely driven by prescriptions for amphetamine salts. Future research initiatives should continue to monitor this trend and in prescriptions and associated abuse in the setting of rising amphetamine abuse.

Purpose of Review The purpose of this review is to investigate the current use and effectiveness of active surveillance (AS) for clinical low-risk prostate cancer (PCa) in men considered to be “high-risk” based on the factors of race, genetics, healthcare access, and socioeconomic status. Recent Findings Advances in molecular biomarkers and imaging have improved the detection, risk stratification, and treatment of PCa. Still, overdiagnosis and overtreatment of indolent disease remain a concern. AS is therefore the preferred option for clinical low-risk disease. Yet, because of the variability in PCa presentation based on the aforementioned environmental and genetic factors, the question remains: Is active surveillance a safe option for everyone? Summary Provider hesitancy should not necessarily exclude high-risk men from participating in AS. Rather, clinicians should employ shared decision-making, sound clinical judgment, and stringent follow-up in order to effectively counsel AS candidates and optimize AS-related outcomes in “high-risk” individuals.

Breast cancer (BC) stem cells (CSCs) resist treatment and can exist as dormant cells in tissues such as the bone marrow (BM). Years before clinical diagnosis, BC cells (BCCs) could migrate from the primary site where the BM niche cells facilitate dedifferentiation into CSCs. Additionally, dedifferentiation could occur by cell autonomous methods. Here we studied the role of Msi 1, a RNA-binding protein, Musashi I (Msi 1). We also analyzed its relationship with the T-cell inhibitory molecule programmed death-ligand 1 (PD-L1) in CSCs. PD-L1 is an immune checkpoint that is a target in immune therapy for cancers. Msi 1 can support BCC growth through stabilization of oncogenic transcripts and modulation of stem cell-related gene expression. We reported on a role for Msi 1 to maintain CSCs. This seemed to occur by the differentiation of CSCs to more matured BCCs. This correlated with increased transition from cycling quiescence and reduced expression of stem cell-linked genes. CSCs co-expressed Msi 1 and PD-L1. Msi 1 knockdown led to a significant decrease in CSCs with undetectable PD-L1. This study has implications for Msi 1 as a therapeutic target, in combination with immune checkpoint inhibitor. Such treatment could also prevent dedifferentiation of breast cancer to CSCs, and to reverse tumor dormancy. The proposed combined treatment might be appropriate for other solid tumors.

Purpose To evaluate the clinical and radiological results of the operative management of three-column uncomplicated type «B» subaxial injures treated with a one-level cervical corpectomy with an expandable cage. Methods This study included 72 patients with a three-column uncomplicated type «B» subaxial injures who met the inclusion criteria, underwent a one-level cervical corpectomy with an expandable cage at one of three neurosurgical departments between 2005 and 2020, and were followed up for clinical and radiological outcomes at a minimum 3-yr follow-up. Results There was a decrease in the VAS pain score from an average of 80 mm to 7 mm (p = 0.03); a decrease in the average NDI score from 62 to 14% (p = 0.01); excellent and good outcomes according to Macnab’s scale were 93% (n = 67/72). There was an average change in the cervical lordosis (Cobb method) from −9.10 to −15.40 (p = 0.007), without significant loss of lordosis (p = 0.27). There was no significant degeneration of the adjacent levels by 3 years post-op. The fusion rate, using the Cervical Spine Research Society criteria, was poor: it was 62.5% (n = 45/72), and using the CT criteria, it was 65.3% (n = 47/72). 15.4% patients (n = 11/72) suffered complications. Statistical difference between the fusion and pseudoarthrosis (according to X-ray criteria) subgroups showed that there were no statistically significant differences in the smoking status, diabetes, chronic steroid use, cervical injury level, subtypes of AO type B subaxial injuries and types of expandable cage systems. Conclusions One-level cervical corpectomy with an expandable cage, despite a poor fusion rate, can be considered a feasible and relatively safe method for treating three-column uncomplicated subaxial type «B» injures, with the benefit of immediate stability, anatomical reduction, and direct decompression of the spinal cord. While no one in our series had any catastrophic complications, we did note a high complication rate.

Introduction: OnabotulinumtoxinA is commonly used to relieve spasticity in children with neurologic disorders. Ethanol neurolysis may be used to target more muscles, but is less well studied, especially in pediatrics. Objective: This prospective quality improvement study aimed to determine the safety and effectiveness of ethanol neurolysis with onabotulinumtoxinA injections compared to only onabotulinumtoxinA injections for the treatment of spasticity in children with cerebral palsy. Design: Cohort study including patients with cerebral palsy receiving onabotulinumtoxinA and/or ethanol neurolysis from June 2020 to June 2021. Setting: Outpatient physiatry clinic. Patients: A total of 167 children with cerebral palsy not undergoing other treatments during injection period. Interventions: Injection with either onabotulinumtoxinA only (112 children) or a combination of ethanol and onabotulinumtoxinA injections (55 children) using both ultrasound guidance and electrical stimulation. Main outcome measures: A post-procedure evaluation at 2 weeks post-injection documented any adverse effects experienced by the child and perceived magnitude of improvement using an ordinal scale from 1-5. Multiple linear regression was used to identify and control for covariates including Gross Motor Function Classification System (GMFCS), sex, age, weight, ethnicity, race, and dosage RESULTS: Only weight was identified as a confounding factor. When controlled for weight, combined BTX-A and ethanol injections of onabotulinumtoxinA and alcohol had a greater magnitude of improvement (3.78/5) compared to onabotulinumtoxinA injections alone (3.44/5), a difference of 0.34 points on the rating scale (0.01-0.69 95% CI; p=0.045). However, the difference was not clinically significant. Looking at adverse effects, one patient in the onabotulinumtoxinA-only group and two patients in the combined BTX-A and ethanol group reported mild, self-limiting adverse effects. Conclusion: Ethanol neurolysis under ultrasound and electrical stimulation guidance may be a safe and effective treatment for children with cerebral palsy that allows more spastic muscles to be treated than onabotulinumtoxinA alone.

Food allergy (FA) is a growing issue worldwide. The United Kingdom (UK) and United States (US) are high-income, industrialized countries with reported increases in FA prevalence over the past few decades. This review compares delivery of FA care in the UK and US and each country's response to the heightened demand and disparities for FA services. In the UK, allergy specialists are scarce and general practitioners (GPs) provide most allergy care. While the US has more allergists per capita than the UK, there is still a shortage of allergy services owing to the greater reliance on specialist care for FA in America and wide geographic variation in access to allergist services. At this time, generalists in these countries lack the specialty training and equipment to optimally diagnose and manage FA. Moving forward, the UK aims to enhance training for GPs so they may provide better quality frontline allergy care. In addition, the UK is implementing a new tier of semi-specialized GPs and increasing cross-center collaboration through clinical networks. The UK and US aim to increase the number of FA specialists, which is critical at a time of rapidly expanding management options for allergic and immunologic diseases requiring clinical expertise and shared decision-making to select appropriate therapies. While these countries aim to actively grow their supply of quality FA services, further efforts to build clinical networks, and perhaps, recruit international medical graduates and expand telehealth services, are necessary to reduce disparities in access to care. For the UK in particular, this will require additional support from the leadership of the centralized National Health Service, which remains challenging.

Background: Individuals with spinal cord injury (SCI) above thoracic level-6 (T6) experience impaired descending cortical control of the autonomic nervous system which predisposes them to blood pressure (BP) instability, including includes hypotension, orthostatic hypotension (OH), and autonomic dysreflexia (AD). However, many individuals do not report symptoms of these BP disorders, and because there are few treatment options that have been proven safe and effective for use in the SCI population, most individuals remain untreated. Objective: The primary aim of this investigation was to determine the effects of midodrine (10 mg) prescribed TID or BID in the home environment, compared to placebo, on 30-day BP, study withdrawals, and symptom reporting associated with OH and AD in hypotensive individuals with SCI. Design/methods: Participants were randomly assigned to received midodrine/placebo or placebo/midodrine, with a 2-weeks washout period in between, and both the participants and investigators were blinded to randomization order. Study medication was taken 2 or 3 times/day, depending on their sleep/wake schedule, BP, and any related symptoms were recorded before and 1 h after each dosage and periodically throughout the day. Results: Nineteen individuals with SCI were recruited; however, 9 withdrew prior to completion of the full protocol. A total of 1892 BP recordings (75 ± 48 recordings/participant/30-day period) were collected in the 19 participants over the two 30-day monitoring periods. Average 30-day systolic BP was significantly increased with midodrine compared to placebo (114 ± 14 vs. 96 ± 11 mmHg, respectively; P = 0.004), and midodrine significantly reduced the number of hypotensive BP recordings compared to placebo (38.7 ± 41.9 vs. 73.3 ± 40.6, respectively; P = 0.01). However, compared to placebo, midodrine increased fluctuations in BP, did not improve symptoms of OH, but did significantly worsen the intensity of symptoms associated with AD (P = 0.03). Conclusion: Midodrine (10 mg) administered in the home environment effectively increases BP and reduces the incidence of hypotension; however these beneficial effects come at the expense of worsened BP instability and AD symptom intensity.

Histoplasmosis is a neglected mycosis with high mortality in immunocompromised individuals. The diagnosis can be delayed due to nonspecific clinical manifestations and similar morphology with other organisms. A high index of suspicion is required.

1,25(OH)2D3-mediated intestinal calcium (Ca) absorption supplies Ca for proper bone mineralization during growth. We tested whether vitamin D receptor (VDR)-mediated 1,25(OH)2D3 signaling is critical for adult Ca absorption and bone by using mice with inducible Vdr gene knockout in the whole intestine (villin-CreERT2+/- x VDRf/f, WIK) or in the large intestine (CDX2-CreERT2+/-x VDRf/f, LIK). At 4-month-old, Vdr alleles were recombined (0.05 mg tamoxifen/g BW, i.p., 5-d) and mice were fed diets with either 0.5% (adequate) or 0.2% (low) Ca. Ca absorption was examined after 2 weeks while serum 1,25(OH)2D3, bone mass, and bone microarchitecture were examined after 16 weeks. Intestinal and renal gene expression was measured at both time points (n = 12/genotype/diet/time point). On the 0.5% Ca diet, all phenotypes in WIK and LIK mice were similar to the controls. Control mice adapted to the 0.2% low Ca diet by increasing renal Cyp27b1 mRNA (3-fold), serum 1,25(OH)2D3 level (1.9-fold), and Ca absorption in the duodenum (Dd, + 131%) and proximal colon (PCo, + 28.9%), which prevented bone loss. In WIK mice, low Ca diet increased serum 1,25(OH)2D3 (4.4-fold) but Ca absorption remained unaltered in Dd and PCo. Consequently, significant bone loss occurred in WIK mice (e.g. cortical thickness, Ct.Th, -33.7%). LIK mice adapted to the low Ca diet in the Dd but not the PCo and the impact on bone phenotypes was milder (e.g. Ct.Th, -13.1%). Our data suggest intestinal VDR in adult mice prevents bone loss under low calcium intake but is dispensable under adequate calcium intake.

Methods: Symptoms were assessed immediately following completion of a rugby match (median 60 minutes). Players removed from the match for assessment due to a head hit were classified as head injured. Controls completed match without head hit. Results: 209 players (67 female; 33 ± 13 years) participated with 80 experiencing a head injury. Symptom severity was significantly greater in head injured (26.2 ± 17.6) compared with controls (8.9 ± 11.5, P < 0.001). 21% of control players reporting >16 symptom severity, misclassifying them as suspected concussion. There were no significant sex differences. Factor analysis produced four symptom clusters of which Headache was most discriminatory between the head injured (median = 1.7) and controls (median = 0.0). Conclusion: These findings demonstrate that exercise and contact during a game affect symptom assessment, increasing the likelihood of misclassifying players with suspected concussion. Factor characterization of symptoms associated with head injury using an exercised comparison group provides more useful discrimination. These results highlight the necessity for objective measures to diagnose concussions outside of symptom self-report.

Background and study aims Endoscopic necrosectomy is limited by the proximity of necrosis to the gastrointestinal tract. Percutaneous endoscopic necrosectomy (PEN) is a minimally invasive endoscopic method of percutaneous debridement. Studies regarding its efficacy and safety are lacking. The purpose of this study was to assess the efficacy and safety of PEN in necrotizing pancreatitis. Methods Pubmed, Ovid, Cochrane, Scopus and Web of Science Database were searched from inception through February 2021. Dual extraction and quality assessment of studies using Cochrane risk of bias tool were performed independently by two authors. The primary outcome was defined as clinical success of PEN. Secondary outcomes included periprocedural morbidity, mortality, and long-term morbidity and mortality. Results Sixteen observational studies including 282 subjects were analyzed. The average reported age of the participants was 50.3 years. Patients with reported gender included 39 % females and 61 % males. The success rate as defined by complete resolution of necrosis and removal of drainage catheters/stents was 82 % (95 % confidence interval 77–87). The mean size of pancreatic necrosis was 14.86 cm (5–54 cm). The periprocedural morbidity rate was 10 %, while there was no reported periprocedural mortality. The long-term morbidity rate was reported as 23 % and mortality at follow-up was 16 %. Conclusions PEN is a novel method of endoscopic management of pancreatic necrosis. Based on our meta-analysis of retrospective studies, it represents a safe treatment modality with high rates of clinical success and low rates of perioperative morbidity and mortality. This study supports the use of PEN when conventional endoscopic therapy is not feasible.

Background Anti-Black racism is prevalent in medicine, and anti-racism training is needed in medical education. One such training is the Presence 5 for Racial Justice (P5RJ) Curriculum which covers evidence-based anti-racism communication strategies that promote health equity for Black patients. The P5RJ Curriculum was developed using feedback from clinicians and trainees with diversity, equity, and inclusion (DEI) experience. In this study, we identify themes in recommended anti-racism language and phrases that surveyed clinicians and trainees use to promote racial justice and health equity in clinical care for Black patients. Methods Secondary analysis of survey responses to identify themes in qualitative data. Dataset: Survey responses of specific phrases for anti-racism communication based on P5RJ Curriculum feedback. Population studied: N = 50 respondents (27 clinicians, 17 medical trainees, 6 unreported) recruited through convenience sampling and listservs of clinicians with DEI experience. An inductive qualitative analysis was performed on survey responses to identify emerging themes. Results Emerging themes from survey responses reflected four communication practices: “Inquiry” was the predominant practice (59%), followed by “Empathy” (25%), “Statements of Allyship” (9%), and “Self-Accountability” (8%). Conclusion Inquiry and empathy may be predominant communication practices when addressing anti-Black racism in medicine. There is an opportunity to expand anti-racism communication tools with statements of self-accountability and allyship. Future research is necessary to analyze the patient voice on clinician communication practices that promote anti-racism in clinical care.

The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) developed consensus statements on pre-invasive vulvar lesions in order to improve the quality of care for patients with vaginal intraepithelial neoplasia (VaIN). The management of VaIN varies according to the grade of the lesion: VaIN 1 (low grade vaginal squamous intraepithelial lesions (SIL)) can be subjected to follow-up, while VaIN 2–3 (high-grade vaginal SIL) should be treated. Treatment needs individualization according to the patient’s characteristics, disease extension and previous therapeutic procedures. Surgical excision is the mainstay of treatment and should be performed if invasion cannot be excluded. Total vaginectomy is used only in highly selected cases of extensive and persistent disease. Carbon dioxide (CO 2 ) laser may be used as both an ablation method and an excisional one. Reported cure rates after laser excision and laser ablation are similar. Topical agents are useful for persistent, multifocal lesions or for patients who cannot undergo surgical treatment. Imiquimod was associated with the lowest recurrence rate, highest human papillomavirus (HPV) clearance, and can be considered the best topical approach. Trichloroacetic acid and 5-fluorouracil are historical options and should be discouraged. For VaIN after hysterectomy for cervical intraepithelial neoplasia (CIN) 3, laser vaporization and topical agents are not the best options, since they cannot reach epithelium buried in the vaginal scar. In these cases surgical options are preferable. Brachytherapy has a high overall success rate but due to late side effects should be reserved for poor surgical candidates, having multifocal disease, and with failed prior treatments. VaIN tends to recur and ensuring patient adherence to close follow-up visits is of the utmost importance. The first evaluation should be performed at 6 months with cytology and an HPV test during 2 years and annually thereafter. The implementation of vaccination against HPV infection is expected to contribute to the prevention of VaIN and thus cancer of the vagina. The effects of treatment can have an impact on quality of life and result in psychological and psychosexual issues which should be addressed. Patients with VaIN need clear and up-to-date information on a range of treatment options including risks and benefits, as well as the need for follow-up and the risk of recurrence.

Introduction: Data-driven approaches to transcranial magnetic stimulation (TMS) might yield more consistent and symptom-specific results based on individualized functional connectivity analyses compared to previous traditional approaches due to more precise targeting. We provide a proof of concept for an agile target selection paradigm based on using connectomic methods that can be used to detect patient-specific abnormal functional connectivity, guide treatment aimed at the most abnormal regions, and optimize the rapid development of new hypotheses for future study. Methods: We used the resting-state functional MRI data of 28 patients with medically refractory generalized anxiety disorder to perform agile target selection based on abnormal functional connectivity patterns between the Default Mode Network (DMN) and Central Executive Network (CEN). The most abnormal areas of connectivity within these regions were selected for subsequent targeted TMS treatment by a machine learning based on an anomalous functional connectivity detection matrix. Areas with mostly hyperconnectivity were stimulated with continuous theta burst stimulation and the converse with intermittent theta burst stimulation. An image-guided accelerated theta burst stimulation paradigm was used for treatment. Results: Areas 8Av and PGs demonstrated consistent abnormalities, particularly in the left hemisphere. Significant improvements were demonstrated in anxiety symptoms, and few, minor complications were reported (fatigue (n = 2) and headache (n = 1)). Conclusions: Our study suggests that a left-lateralized DMN is likely the primary functional network disturbed in anxiety-related disorders, which can be improved by identifying and targeting abnormal regions with a rapid, data-driven, agile aTBS treatment on an individualized basis.

Purpose of Review Despite more than 6 decades of growth and transformation, the field of cancer rehabilitation has considerable room to evolve if it is to live up to its full potential. This article will discuss the importance of this evolution in the context of radiation late effects and serve as a call for the clinical and operational expansion of the field so that it can become a key component of comprehensive cancer care. Recent Findings The clinical and operational challenges inherent in cancer survivors with radiation late effects necessitate different thinking with respect to how rehabilitation professionals evaluate and manage patients as well as how our institutions equip these professionals to practice at the highest possible level. Summary To achieve its promise, the field of cancer rehabilitation must evolve to embrace fully the scope, scale, and complexity of issues faced by cancer survivors with radiation late effects. Better engagement and coordination of the care team are needed to deliver this care and ensure our programs are robust, sustainable, and flexible.

Sport-related concussion (SRC) affects an estimated 1.6 to 3.8 million Americans each year. Sport-related concussion results from biomechanical forces to the head or neck that lead to a broad range of neurologic symptoms and impaired cognitive function. Although most individuals recover within weeks, some develop chronic symptoms. The heterogeneity of both the clinical presentation and the underlying brain injury profile make SRC a challenging condition. Adding to this challenge, there is also a lack of objective and reliable biomarkers to support diagnosis, to inform clinical decision making, and to monitor recovery after SRC. In this review, the authors provide an overview of advanced neuroimaging techniques that provide the sensitivity needed to capture subtle changes in brain structure, metabolism, function, and perfusion after SRC. This is followed by a discussion of emerging neuroimaging techniques, as well as current efforts of international research consortia committed to the study of SRC. Finally, the authors emphasize the need for advanced multimodal neuroimaging to develop objective biomarkers that will inform targeted treatment strategies after SRC.

ALG13-CDG is a rare X-linked disorder of N-linked glycosylation. Given the lack of long-term outcome data in ALG13-CDG, we collected natural history data and reviewed individuals surviving to young adulthood with confirmed pathogenic variants in ALG13 in our own cohort and in the literature. From the 14 ALG13-CDG patients enrolled into our Frontiers of Congenital Disorders of Glycosylation Consortium natural history study only two patients were older than 16 years; one of these two females is so far unreported. From the 52 patients described in the medical literature with confirmed pathogenic variants in ALG13 only five patients were older than 16 years (all females), in addition to the new, unreported patient from our natural history study. Two male patients have died due to ALG13-CDG, and there were no surviving males older than 16 years with a confirmed ALG13-CDG diagnosis. Our adolescent and young adult cohort of six patients presented with epilepsy, muscular hypotonia, speech, and developmental delay. Intellectual disability was present in all female patients with ALG13-CDG. Unreported features included ataxia, neuropathy, and severe gastrointestinal symptoms requiring G/J tube placement. In addition, two patients from our natural history study developed unilateral hearing loss. Skeletal abnormalities were found in four patients, including osteopenia and scoliosis. Major health problems included persistent seizures in three patients. Ketogenic diet was efficient for seizures in three out of four patients. Although all patients were mobile, they all had severe communication problems with mostly absent speech and were unable to function without parental support. In summary, long-term outcome in ALG13-CDG includes gastrointestinal and skeletal involvement in addition to a chronic, mostly non-progressive neurologic phenotype.

Point mutations in leucine-rich repeat kinase 2 (LRRK2) which cause Parkinson's disease increase its kinase activity, and a subset of Rab GTPases have been identified as endogenous LRRK2 kinase substrates. Their phosphorylation correlates with a loss-of-function for the membrane trafficking steps they are normally involved in, but it also allows them to bind to a novel set of effector proteins with dominant cellular consequences. In this brief review, we will summarize novel findings related to the LRRK2-mediated phosphorylation of Rab GTPases and its various cellular consequences in vitro and in the intact brain, and we will highlight major outstanding questions in the field.

Background Traumatic spinal cord injury (tSCI) is a debilitating condition, leading to chronic morbidity and mortality. In recent peer-reviewed studies, spinal cord epidural stimulation (scES) enabled voluntary movement and return of over-ground walking in a small number of patients with motor complete SCI. Using the most extensive case series ( n = 25) for chronic SCI, the present report describes our motor and cardiovascular and functional outcomes, surgical and training complication rates, quality of life (QOL) improvements, and patient satisfaction results after scES. Methods This prospective study occurred at the University of Louisville from 2009 to 2020. scES interventions began 2–3 weeks after surgical implantation of the scES device. Perioperative complications were recorded as well as long-term complications during training and device related events. QOL outcomes and patient satisfaction were evaluated using the impairment domains model and a global patient satisfaction scale, respectively. Results Twenty-five patients (80% male, mean age of 30.9 ± 9.4 years) with chronic motor complete tSCI underwent scES using an epidural paddle electrode and internal pulse generator. The interval from SCI to scES implantation was 5.9 ± 3.4 years. Two participants (8%) developed infections, and three additional patients required washouts (12%). All participants achieved voluntary movement after implantation. A total of 17 research participants (85%) reported that the procedure either met ( n = 9) or exceeded ( n = 8) their expectations, and 100% would undergo the operation again. Conclusion scES in this series was safe and achieved numerous benefits on motor and cardiovascular regulation and improved patient-reported QOL in multiple domains, with a high degree of patient satisfaction. The multiple previously unreported benefits beyond improvements in motor function render scES a promising option for improving QOL after motor complete SCI. Further studies may quantify these other benefits and clarify scES’s role in SCI patients.