AOSpine—Spine Trauma Classification System: The Value of Modifiers: A Narrative Review With Commentary on Evolving Descriptive Principles

Study Design: Narrative review. Objectives: To describe the current AOSpine Trauma Classification system for spinal trauma and highlight the value of patient-specific modifiers for facilitating communication and nuances in treatment. Methods: The classification for spine trauma previously developed by The AOSpine Knowledge Forum is reviewed and the importance of case modifiers in this system is discussed. Results: A successful classification system facilitates communication and agreement between physicians while also determining injury severity and provides guidance on prognosis and treatment. As each injury may be unique among different patients, the importance of considering patient-specific characteristics is highlighted in this review. In the current AOSpine Trauma Classification, the spinal column is divided into 4 regions: the upper cervical spine (C0-C2), subaxial cervical spine (C3-C7), thoracolumbar spine (T1-L5), and the sacral spine (S1-S5, including coccyx). Each region is classified according to a hierarchical system with increasing levels of injury or instability and represents the morphology of the injury, neurologic status, and clinical modifiers. Specifically, these clinical modifiers are denoted starting with M followed by a number. They describe unique conditions that may change treatment approach such as the presence of significant soft tissue damage, uncertainty about posterior tension band injury, or the presence of a critical disc herniation in a cervical bilateral facet dislocation. These characteristics are described in detail for each spinal region. Conclusions: Patient-specific modifiers in the AOSpine Trauma Classification highlight unique clinical characteristics for each injury and facilitate communication and treatment between surgeons

Cast-Saw Burns: Evaluation of Skin, Cast, and Blade Temperatures Generated During Cast Removal

Background: The use of an oscillating saw for cast removal creates a potential for iatrogenic injury and patient discomfort. Burns and abrasions can occur from the heat created by frictional forces and direct blade contact. With use of a cadaver model system, skin temperature measurements were recorded during cast removal with an oscillating saw. Methods: Casts of uniform thickness were applied to cadavers equilibrated to body temperature. The casts were removed by a single individual while simultaneously measuring temperatures at the skin-padding interface, cast-padding interface, and the blade. Variables tested include two removal techniques, two casting materials (fiberglass and plaster), and two cast-padding thicknesses. Results: A poor removal technique (the cast saw blade never leaving the cast material during cutting), fiberglass casting material, and thinner cast padding resulted in significantly higher skin temperatures. The poor technique increased skin temperatures by an average of 5.0°C (p \u3c 0.05). Fiberglass casting materials increased skin temperatures by an average of 7.4°C (p \u3c 0.05). Four layers of cast padding compared with two layers decreased skin temperatures by 8.0°C (p \u3c 0.05). Conclusions: The highest skin temperatures were recorded for fiberglass casts with two layers of padding. The lowest skin temperatures were recorded for plaster casts with four layers of padding. Four layers of cast padding compared with two layers significantly reduced skin temperatures for both plaster and fiberglass casts. Clinical Relevance: A routine assessment of the layers of padding and the type of cast material prior to splitting casts with an oscillating saw can help clinicians to identify cast removal conditions with a higher risk for causing patient discomfort, abrasions, or burns

Four-year experience with methotrexate exposures.

INTRODUCTION: Unintentional methotrexate (MTX) acute oral overdose is rarely reported. METHODS: We conducted a retrospective chart review of all human exposure calls (\u3e150,000 charts) for MTX ingestions reported to our Poison Center during 2000-2003. RESULTS: Thirteen patients met the criteria. The average amount of MTX ingested was 13.03 mg (data from 7 cases), and the average patient age was 43 years (20 months to 80 years). No significant toxicities occurred. DISCUSSION: Although intravenous MTX toxicity can be severe, this does not appear to be a phenomenon associated with either acute unintentional or suicidal oral ingestion

Teen perception of texting and driving in rural West Virginia

In the last decade, texting and driving has evolved into a serious problem among the adolescent population. The goal of this study was to determine if education can effectively raise awareness of the dangers of texting and driving and positively influence the behavior of rural West Virginia teens. A 25 question survey designed to asses teen driving behavior was administered to 143 rural West Virginia high school students before and after and educational session. The educational session was designed to explain how texting and driving impairs driving ability and show graphic images of accidents and injuries that resulted from this behavior. Pre and post-lecture survey responses were then analyzed. The survey results revealed that texting and driving is highly prevalent among rural West Virginia teens, with 57% of teens admitting to this behavior. Around 73% of teens agreed that texting and driving was very dangerous, but many continued to do so regardless. Additionally, 59% admitted to talking on the phone while driving, and 11% admitted to drinking and driving. A single lecture was not observed to reduce texting and driving behavior among the study population. More research is needed to establish an effective method to reduce this dangerous behavior

Neurologic improvement after thoracic, thoracolumbar, and lumbar spinal cord (conus medullaris) injuries

Study Design. Retrospective. Objective. With approximately 10,000 new spinal cord injury (SCI) patients in the United States each year, predicting public health outcomes is an important public health concern. Combining all regions of the spine in SCI trials may be misleading if the lumbar and sacral regions (conus) have a neurologic improvement at different rates than the thoracic or thoracolumbar spinal cord. Summary of Background Data. Over a 10-year period between January 1995 to 2005, 1746 consecutive spinal injured patients were seen, evaluated, and treated through a level 1 trauma referral center. A retrospective analysis was performed on 150 patients meeting the criteria of T4 to S5 injury, excluding gunshot wounds. One-year follow-up data were available on 95 of these patients. Methods. Contingency table analyses (chi-squared statistics) and multivariate logistic regression. Variables of interest included level of injury, initial American Spinal Injury Association (ASIA), age, race, and etiology. Results. A total of 92.9% of lumbar (conus) patients neurologically improved one ASIA level or more compared with 22.4% of thoracic or thoracolumbar spinal cord-injured patients. Only 7.7% of ASIA A patients showed neurologic improvement, compared with 95.2% of ASIA D patients; ASIA B patients demonstrated a 66.7% improvement rate, whereas ASIA C had a 84.6% improvement rate. When the two effects were considered jointly in a multivariate analysis, ASIA A and thoracic/thoracolumbar patients had only a 4.1% rate of improvement, compared with 96% for lumbar (conus) and incomplete patients (ASIA B-D) and 66.7% to 72.2% for the rest of the patients. All of these relationships were significant to P \u3c 0.001 (chi-square test). There was no link to age or gender, and race and etiology were secondary to region and severity of injury. Conclusion. Thoracic (T4-T9) SCIs have the least potential for neurologic improvement. Thoracolumbar (T10-T12) and lumbar (conus) spinal cord have a greater neurologic improvement rate, which might be related to a greater proportion of lower motor neurons. Thus, defining the exact region of injury and potential for neurologic improvement should be considered in future clinical trial design. Combining all anatomic regions of the spine in SCI trials may be misleading if different regions have neurologic improvement at different rates. Over a ten-year period, 95 complete thoracic/thoracolumbar SCI patients had only a 4.1% rate of neurologic improvement, compared with 96.0% for incomplete lumbar (conus) patients and 66.7% to 72.2% for all others

Risk Factors Associated with a Second Primary Lung Cancer in Patients with an Initial Primary Lung Cancer

Objectives: Increased patient survivorship following initial primary lung cancer (IPLC) due to advancing clinical practice has uncovered new clinical challenges. With growing patient longevity, individuals post-IPLC continue to be at higher subsequent risk of developing secondary primary lung cancer (SPLC). Proper SPLC surveillance guidelines aimed at monitoring IPLC survivors is crucial to enhancing life expectancy in this population. This study aims to categorize risk factors associated with SPLC emergence in IPLC survivors for clinical use following IPLC treatment. Materials and Methods: Using the Karmanos Cancer Institute Tumor Registry, patients diagnosed with IPLC from 2000 to 2017 were identified. Patients diagnosed with SPLC were matched for histology, age and stage to individuals who did not develop SPLC. Logistic and Cox regression analyses were performed to identify potential risk factors for SPLC emergence and overall survival. Results: 121 patients diagnosed with IPLC who later developed SPLC were identified and compared to 120 patients with IPLC who did not develop SPLC. Patients who did not undergo surgical resection had a significantly lower probability of developing SPLC (OR 0.235, 95% confidence interval [CI]: 0.118 to 0.450; p\u3c0.001). Compared to surgical resection patients, individuals who did not have surgery as their primary treatment for IPLC had a significantly higher hazard of death (HR 3.088, 95% CI: 2.114 to 4.512; p\u3c0.001). Conclusion: This study uncovered notable associations and lack thereof between several competing risk factors and SPLC development as well as mortality. Further characterization of SPLC risk factors is essential for implementing effective surveillance recommendations

Damage to the prefrontal cortex increases utilitarian moral judgements

The psychological and neurobiological processes underlying moral judgement have been the focus of many recent empirical studies1–11. Of central interest is whether emotions play a causal role in moral judgement, and, in parallel, how emotion-related areas of the brain contribute to moral judgement. Here we show that six patients with focal bilateral damage to the ventromedial prefrontal cortex (VMPC), a brain region necessary for the normal generation of emotions and, in particular, social emotions12–14, produce an abnor- mally ‘utilitarian’ pattern of judgements on moral dilemmas that pit compelling considerations of aggregate welfare against highly emotionally aversive behaviours (for example, having to sacrifice one person’s life to save a number of other lives)7,8. In contrast, the VMPC patients’ judgements were normal in other classes of moral dilemmas. These findings indicate that, for a selective set of moral dilemmas, the VMPC is critical for normal judgements of right and wrong. The findings support a necessary role for emotion in the generation of those judgements