Enhancing agreement in classification and surgical approach selection for tibial plateau fractures: The role of identifying metaphyseal fracture exit. - A Cross-sectional study

Objectives

To determine if identifying the metaphyseal exit can enhance intra- and inter-observer agreement in utilizing the Kfuri and Schatzker anatomical classification and selecting the appropriate surgical approach for tibial plateau fractures.

Methods

Design: Cross-sectional observational study.Setting: Academic hospital with access to advanced imaging technologies.Patient Selection Criteria: Tibial plateau fracture cases from January 2019 to March 2021 with complete image sets (AP and lateral knee radiographs, CT scans). Exclusion criteria included periprosthetic, neglected, or pathological fractures.Outcome Measures and Comparisons: Primary outcome measures were intra- and inter-observer agreement in fracture classification and surgical approach selection, quantified using Cohen's and Fleiss Kappa coefficients.

Results

The study analyzed 63 cases. Intra-observer agreement improved from moderate to 'very good,' especially in the third evaluation phase when the metaphyseal exit was identified alongside 3D CT imaging. Inter-observer agreement was generally low but improved when comprehensive image sets were available. Notably, the most experienced evaluator demonstrated significantly higher agreement in both fracture classification and surgical approach selection.

Conclusions

The identification of metaphyseal exit points significantly enhances agreement in fracture classification and surgical approach selection, addressing limitations of traditional systems. While surgeon experience and imaging availability remain critical, incorporating the metaphyseal exit into the Kfuri and Schatzker classification offers a reproducible framework for guiding treatment decisions.

Level of evidence

III Diagnostic Study.

The (neuro)inflammatory system in anxiety disorders and PTSD: Potential treatment targets

Targeting the immune system has recently garnered attention in the treatment of stress- associated psychiatric disorders resistant to existing pharmacotherapeutics. While such approaches have been studied in considerable detail in depression, the role of (neuro)inflammation in anxiety-related disorders, or in anxiety as an important transdiagnostic symptom, is much less clear. In this review we first critically review clinical and in part preclinical evidence of central and peripheral immune dysregulation in anxiety disorders and post-traumatic stress disorder (PTSD) and briefly discuss proposed mechanisms of how inflammation can affect anxiety-related symptoms. We then give an overview of existing and potential future targets in inflammation-associated signal transduction pathways and discuss effects of different immune-modulatory drugs in anxiety-related disorders. Finally, we discuss key gaps in current clinical trials such as the lack of prospective studies involving anxiety patient stratification strategies based on inflammatory biomarkers. Overall, although evidence is rather limited so far, there is data to indicate that increased (neuro)inflammation is present in subgroups of anxiety disorder patients. Although exact identification of such immune subtypes of anxiety disorders and PTSD is still challenging, these patients will likely particularly benefit from therapeutic targeting of aspects of the inflammatory system. Different anti-inflammatory treatment approaches (microglia-directed treatments, pro-inflammatory cytokine inhibitors, COX-inhibitors, phytochemicals and a number of novel anti-inflammatory agents) have indeed shown some efficacy even in non-stratified anxiety patient groups and appear promising as novel alternative or complimentary therapeutic options in specific ("inflammatory") subtypes of anxiety disorder and PTSD patients.

Assessing the costs of midfoot arthrodesis: A retrospective cohort study

This retrospective cohort study aims to determine the economic cost of midfoot arthrodesis when treating midfoot arthritis, identifying the major driving forces of cost. A retrospective analysis was conducted on midfoot arthrodesis cases in South Carolina from 2012 to 2020 using the South Carolina Revenue and Fiscal Affairs (SCRFA) database. Patient cases were identified by ICD-9, ICD-10, or CPT code, yielding a total of 1,313 cases included in our analysis. Patients undergoing midfoot arthrodesis were primarily female (71.1 %), Caucasian (74.6 %), insured through commercial insurance (40.2 %) or Medicare (37.3 %), and had a mean age of 54.27 years (range 4-86). The mean total cost per midfoot arthrodesis was $54,307.08 (range $9,433.05-$120,664.29) and the mean length of stay was 1.26 (range 1-6) days. Total charges trended upward from $42,857 in 2012 to $58,643.43 in 2020. Upon analysis, the largest contributors to this cost were supplies ($27,888.28), operating room costs ($15,876.80), and anesthesia costs ($3,866.70). Notably, surgeon fees were a comparatively minor contributor ($670.49). The mean total cost per midfoot arthrodesis was $54,307.08, with supplies and operating room costs exceeded 80 % of the mean total costs. With professional service (physician) fees accounting for only 1.2 % of costs, hospital systems, hospital administrators, and surgeons should consider improving their understanding of ways to reduce surgical costs, supply negotiation, and transitioning to more outpatient surgery as means to improve the value of midfoot arthrodesis care. LEVEL OF CLINICAL EVIDENCE: Level IV, Retrospective Cohort Study.

Research and predictive analysis of the disease burden of bloodstream infectious diseases in China

BACKGROUND

Bloodstream Infection(BSI) are one of the leading causes of infection-related mortality worldwide. However, epidemiological data related to BSI in China remain very limited.

METHODS

Based on the Global Burden of Disease(GBD) database, a systematic analysis was conducted on the epidemic trends, pathogen spectrum, and the current status of Antimicrobial Resistance(AMR) related to BSI in China for the year 2021. Additionally, an Autoregressive Integrated Moving Average(ARIMA) time series model was constructed to predict the trend of the disease burden associated with BSI in China from 2022 to 2035.

RESULTS

In terms of pathogens, the top five pathogens causing deaths due to BSI in China are as follows: Staphylococcus aureus, Escherichia coli, Streptococcus pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii. There are significant differences in the pathogens causing BSI across different age groups. The disease burden is heaviest in the elderly population aged 70 and above. Among children under five years old, Staphylococcus aureus, Streptococcus pneumoniae, and Candida species are predominant. From 1990 to 2021, although there has been a gradual decline in mortality rates due to BSI across different age groups (with an approximately 52.4% reduction in age-standardized rates), the disease burden of BSI increases with age. This is especially evident in the population aged 70 and above, where the burden of disease is significantly higher than in other age groups. For instance, in 2021, the mortality rate for individuals aged 70-74 was 149.29 (per 100 K), while for those aged 95 and older, the mortality rate reached as high as 896.71 (per 100 K). On a global scale, the disease burden caused by BSI in China is at a moderate level. According to time series model projections, the mortality burden of BSI in China shows a complex trend toward 2035: the crude mortality rate across all age groups is expected to increase by approximately 14.26%, whereas the age-standardized mortality rate and Disability-Adjusted Life Years(DALYs) are projected to decrease significantly. Notably, the mortality burden is expected to decline most prominently in the 70 + and under 5 age groups, while the 25-44 age group is projected to see minimal change. Conversely, the mortality rates for the 5-49 age group are anticipated to increase slightly.

CONCLUSION

Staphylococcus aureus and Escherichia coli are key pathogens contributing to the high mortality burden of BSI. Additionally, the heavy burden associated with AMR poses significant challenges to clinical treatment. From 1990 to 2021, the age-standardized mortality rate mortality of BSI patients is gradually decreasing, and the change in BSI mortality will be mainly affected by the changes in population size and age structure. The forecast analysis for 2022-2035 finds that the death burden of the elderly will be the heaviest, and the mortality of people aged 5-49 years will increase slightly. BSI and its related health problems are still major challenges and need continuous attention.

CLINICAL TRIAL

Inapplicability.

Self-reported concussion history is not related to cortical volume in college athletes

The long-term consequences of concussion are still being uncovered but have been linked to disruptions in cognition and psychological well-being. Previous studies focusing on the association between concussion history and structural changes in the brain have reported inconsistent results. We sought to examine the effect of concussion history on cortical volume with a focus on functional networks. These networks are associated with many of the functions that can be disrupted in those with an extensive concussion history. We collected baseline behavioral data including the Immediate Post-Concussion Assessment and Cognitive Testing, a self-report measure of the number of diagnosed concussions, and structural MRI in college athletes (n=296; 263 men and 33 women, age range 17-24). Behavioral measures were collected by members of the Department of Athletics concussion management team using a standardized protocol as part of their on-boarding process. Collegiate athletes in the present study who self-reported concussion history did not report different baseline symptoms and did not exhibit consistent differences in cognitive performance relative to those who reported no concussion history. We found that concussion history was not related to cortical volume at the network or region level, even when we compared participants with two or more concussions to those with no concussion history. We did identify relationships between cortical volume in the visual network and dorsal attention network with cognitive performance. In addition to comparing cortical volume between individuals with and without reported concussion history, we also examined whether cortical volume changes could be observed within individuals from baseline to acutely following concussion. We found that network level cortical volume did not change within subjects from baseline measurement to acutely post-concussion. Together, these results suggest that both self-reported concussion history and acute concussion effects are not associated with changes in cortical volume in young adult athletes.

Evaluating factors associated with the use of extracorporeal membrane oxygenation in major trauma - an analysis of the TraumaRegister DGU®

PURPOSE

There is increasing evidence that use of ECMO is beneficial in major trauma patients with refractory organ failure. Hence, increased numbers of ECMO support following major trauma are reported. We set out to determine the use of ECMO among major trauma patients submitted to the TraumaRegister DGUr® as well as patient features associated with ECMO support.

METHODS

The TraumaRegister DGU® is a multinational database compiling trauma related health care data from point-of-injury, initial and critical care to outcome. Major trauma cases (AIS ≥ 3 irrespective of injury location) with subsequent critical care as well as respiratory and/or circulatory failure (SOFA score ≥ 3 per respective category) enrolled in the TraumaRegister DGU® between 2015 and 2022 were reviewed. A logistic regression model was carried out to evaluate patient features associated with ECMO support.

RESULTS

410/ 22,548 individuals (1.8%) received ECMO support. Survival among ECMO patients was 46.1%. At discharge, good functional outcome as indicated by a Glasgow outcome scale > 3 was observed for 97 ECMO patients (23.6%). Age > 65 (OR 95%-CI 1.90, 1.52-2.60), male sex (OR 1.49, 95%-CI 1.41-1.95), coagulopathy at admission to the emergency department (OR 2.37, 95%-CI 1.88-3.00), chest trauma (OR 2.12, 95%-CI 1.61-2.81), sepsis (OR 2.94, 95%-CI 1.93-2.97), as well as massive transfusion (OR 2.23, 95%-CI1.56-3.19) were associated with the use of ECMO following trauma.

CONCLUSION

In the TraumaRegister DGU®, ECMO for trauma related organ failure remains rare. Among ECMO patients, good functional outcome was observed infrequently. However, the design of the registry did not allow for capturing granular data on ECMO management and timing of organ failure. Hence, outcome data should be interpreted with caution. Nevertheless, evaluation of factors associated with ECMO support after trauma might contribute to early identification of ECMO candidates and improve patient distribution for trauma centers without ECMO capability.

Longitudinal multimodal neuroimaging after traumatic brain injury

Traumatic brain injury is a major cause of long-term cognitive impairment, yet the mechanisms underlying recovery remain poorly understood. Neuroimaging methods such as diffusion MRI, functional MRI, and positron emission tomography (PET) provide insight into micro- and macro-scale changes post-TBI, but the relationships between regional cellular and functional alterations remain unclear. In this study, we conducted a longitudinal, multimodal neuroimaging analysis quantifying TBI-related pathologies in four biomarkers, namely flumazenil PET derived binding potential, dMRI-derived structural connectivity, and resting-state fMRI-derived functional connectivity and fractional amplitude of low-frequency fluctuations in individuals with mild-to-severe brain injury at the subacute (4-6 months post-injury) and chronic (1-year postinjury) stages. Brain injury related regional pathologies, and their changes over time, were correlated across the four biomarkers. Our results reveal complex, dynamic changes over time. We found that flumazenil-PET binding potential was significantly reduced in frontal and thalamic regions in brain injured subjects, consistent with neuronal loss, with partial recovery over time. Functional hyperconnectivity was observed in brain injured subjects initially but declined while remaining elevated compared to non-injured controls, whereas cortical structural hypoconnectivity persisted. Importantly, we observed that brain injury related alterations across MRI modalities became more strongly correlated with flumazenil-PET at the chronic stage. Regions with chronic reductions in flumazenil-PET binding also showed weaker structural node strength and lower amplitude of low frequency fluctuations, a relationship that was not found at the subacute stage. This observation could suggest a progressive convergence of structural and functional disruptions with neuronal loss over time. Additionally, regions with declining structural node strength also exhibited decreases in functional node strength, while these same regions showed increased amplitude of low frequency fluctuations over time. This pattern suggests that heightened intrinsic regional activity may serve as a compensatory mechanism in regions increasingly disconnected due to progressive axonal degradation. Altogether, these findings advance our understanding of how multimodal neuroimaging captures the evolving interplay between neuronal integrity, structural connectivity, and functional dynamics after brain injury. Clarifying these interrelationships could inform prognostic models and enhance knowledge of degenerative, compensatory, and recovery mechanisms in traumatic brain injury.

Mapping the coupling between tract reachability and cortical geometry of the human brain

The study of cortical geometry and connectivity is prevalent in research on the human brain. However, these two aspects of brain structure are usually examined separately, leaving the essential connections between the brain's folding patterns and white matter connectivity unexplored. In this study, we aimed to elucidate fundamental links between cortical geometry and white matter tract connectivity. We developed the concept of tract-geometry coupling (TGC) by optimizing the alignment between tract connectivity to the cortex and multiscale cortical geometry. Specifically, spectral analyses of the cortical surface yielded a set of geometrical eigenmodes, which were then used to explain the locations on the cortical surface reached by specific white matter tracts, referred to as tract reachability. In two independent datasets, we confirmed that tract reachability was well characterized by cortical geometry. We further observed that TGC had high test-retest ability and was specific to each individual. Interestingly, low-frequency TGC was found to be heritable and more informative than the high-frequency components in behavior prediction. Finally, we found that TGC could reproduce task-evoked cortical activation patterns. Collectively, our study provides a new approach to mapping coupling between cortical geometry and connectivity, highlighting how these two aspects jointly shape the connected brain.

Prothrombin time predicting time-dependent and risk-stratified mortality in polytrauma patients

BACKGROUND

Polytrauma is associated with a high mortality rate and often accompanied by coagulopathy. Prothrombin time (PT) is a prognostic factor for mortality in polytrauma patients. The aim was to analyze the time- and severity-dependent role of PT in polytrauma patients related to mortality.

METHODS

Patients (≥ 16 years) with an Injury Severity Score ≥ 16 were retrospectively included, yielding 2890 cases after exclusion criteria. PT was measured at admission and 1, 2, 3, 4, 6, 8, 12, 24, and 48 h thereafter, reported as percentage activity of the reference reagence [%]. According to survival status, two groups were formed and compared. Binary logistic regression was used to test PT as an independent predictor for mortality. A closest top-left threshold method served for calculating threshold values between the survivor and non-survivor group. Patients were divided into subgroups according to PT levels and mortality was assessed for each subgroup at each time point.

RESULTS

PT values in the non-survivor group were lower throughout the measuring period (p < 0.05). PT threshold values declined from admission until 2 h afterwards, reaching less than 50%. Already a slightly compromised PT (≤ 70%) represented a significant factor (p < 0.05) for mortality at early and late time points, associated with a rate of more than 20%. In extremis, PT values of ≤ 25% were related to a mortality rate of more than 50% up to four hours after admission.

CONCLUSION

There are early and significant differences in mortality according to PT values in polytrauma patients (despite resuscitation measures), urging for a fast correction of PT. Time-dependent and stratified referencing may help clinicians estimate the mortality risk and decide upon the extent of surgical care.

Are the same parameters measured at admission and in the ICU comparable in their predictive values for complication and mortality in severely injured patients?

INTRODUCTION

Numerous studies have investigated variables that predict mortality and complications following severe trauma. These studies, however, mainly focus on admission values or a single variable. The aim of this study was to investigate the predictive quality of multiple routine clinical measurements (at admission and in the ICU).

METHODS

Retrospective cohort study of severely injured patients treated at one Level 1 academic trauma centre.

INCLUSION CRITERIA

severe injury (ISS ≥ 16 points), primary admission and complete data set. Exclusion criteria end-of-life treatment based on advanced directive, secondary transferred patients.

PRIMARY OUTCOME

mortality, pneumonia, sepsis. Routine clinical parameters were stratified based on measurement timepoint into Group TB (Trauma Bay, admission) and into Group intensive care unit (ICU, 72 h after admission). Prediction of complications and mortality were calculated using two prediction methods: adaptive boosting (AdaBoost, artificial intelligence, AI) and LASSO regression analysis.

RESULTS

Inclusion of 3668 cases. Overall mean age 45.5 ± 20 years, mean ISS 28.2 ± 15.1 points, incidence pneumonia 19.0%, sepsis 14.9%, death from haemorrhagic shock 4.1%, death from multiple organ failure 1.9%, overall mortality rate 26.8%. Highest predictive value for complications for Group TB include abbreviated injury scale (AIS), new injury severity score (NISS) and systemic Inflammatory Response Syndrome (SIRS) score. Highest predictive quality for complications for Group ICU include late lactate values, haematocrit, leukocytes, and CRP. Sensitivity and specificity of late prediction models using a 25% cutoff were 73.61% and 76.24%, respectively.

CONCLUSIONS

The predictive quality of routine clinical measurements strongly depends on the timepoint of the measurement. Upon admission, the injury severity and affected anatomical regions are more predictive, while during the ICU stay, laboratory parameters are better predictor of adverse outcomes. Therefore, the dynamics of pathophysiologic responses should be taken into consideration, especially during decision making of secondary definitive surgical interventions.

LEVEL OF EVIDENCE

III (retrospective cohort study).

Repeat Discectomy or Instrumented Surgery for Recurrent Lumbar Disk Herniation: An Overview of French Spine Surgeons' Practice

Study designRetrospective multicenter cohort study.ObjectiveRecurrent lumbar disc herniation (ReLDH) is a common condition requiring surgical intervention in a large proportion of cases. Evidence regarding the appropriate choice between repeat microdiscectomy (RD) and instrumented surgery (IS) is lacking. To understand the indications for either of the procedures and compare the results, we aimed to provide an overview of spine surgeon practice in France.MethodsThis retrospective, multicenter analysis included adults who underwent surgery for ReLDHs between December 2020 and May 2021. Surgeons were asked which of the following factors determined their therapeutic choice: radio-clinical considerations, non-discal anatomical factors, patient preference, or surgeon background. Data on preoperative clinical status and radiologic findings were collected. Patient-reported outcome measures (PROMs) were assessed and compared using propensity scores preoperatively and at 3 and 12 months postoperatively.ResultsThe study included 150 patients (72 IS and 78 RD). Radioclinical elements, anatomical data, patient preferences, and surgeon background influenced the choice of RD in 57.7%, 1.3%, 25.6%, and 15.4% of the cases, respectively, and IS in 34.7%, 6.9%, 13.9%, and 44.5% of the cases, respectively. At 12 months, patient satisfaction, return to work, and changes in PROMs were not significantly different between the groups.ConclusionsThe decision-making process included both objective and subjective factors, resulting in patient satisfaction in 80.3% to 81.5% of cases, with significant clinical improvement in radicular symptoms in 75.8% to 91.8% of cases, and quality of life in 75.8% to 84.9% of cases, depending on the procedure performed.

Bleeding management of thoracic trauma

PURPOSE OF REVIEW

Thoracic injuries are directly responsible for 20-30% of deaths in severe trauma patients and represent one of the main regions involved in preventable or potentially preventable deaths. Controlling bleeding in thoracic trauma is a major challenge because intrathoracic hemorrhagic lesions can lead to hemodynamic instability and respiratory failure.

RECENT FINDINGS

The aim of managing intrathoracic hemorrhagic lesions is to control bleeding as quickly as possible and to control any respiratory distress. Extended focus assessment with sonography for trauma enables us to identify intrathoracic bleeding much more quickly and to determine the most appropriate therapeutic strategy.

SUMMARY

Thoracic bleeding can result from the diaphragm, intrathoracic vessels (aorta, but also inferior or superior vena cava, and suprahepatic veins), lung, cardiac, or chest wall injuries. Depending on thoracic lesions (such as hemothorax or hemopericardium), hemodynamic instability, and respiratory failure, a pericardial window approach, sternotomy, thoracotomy, or emergency resuscitation thoracotomy may be considered after discussion with the surgeon. Alongside treatment of injuries, managing oxygenation, ventilation, hemodynamic, and coagulopathy are essential for the patient's outcome.

Clinical Outcome after Endoscopic Facet Denervation in Patients with Chronic Low Back Pain

In mehreren Studien wurde berichtet, dass Kreuzschmerzen in der Bevölkerung mit bis zu 85% eine hohe Prävalenz aufweisen. Die perkutane Radiofrequenz-Facettengelenkdenervation (PRFD) ist heute der Goldstandard bei der Rhizotomie von chronischen Kreuzschmerzen (CLBP). Bisher veröffentlichte Studien zeigen jedoch kontroverse Ergebnisse über die Wirksamkeit der PRFD. Ziel dieser Studie war es daher, den Einsatz der endoskopischen Facettengelenkdenervation (EJE) zur Behandlung chronischer Kreuzschmerzen zu analysieren und potenzielle Risikofaktoren zu ermitteln, die die Indikationen für den Eingriff einschränken könnten.Wir haben retrospektiv 31 Patienten in die Studie eingeschlossen, die seit mindestens 24 Monaten an chronische Kreuzschmerzen leiden. Alle Patienten wurden einer endoskopischen Facettengelenkdenervation unterzogen und mussten postoperativ ODI-, COMI-, EQ-5D- und VRS-Scores ausfüllen, wobei die Nachbeobachtungszeit mindestens 12 Monate betrug. Zur Analyse der Korrelationen wurden grundlegende Patientendaten erfasst.Bei allen gemessenen klinischen Werten, wie ODI, COMI, EQ-5D und VRS, wurde eine signifikante Verbesserung festgestellt. Während das beste Ergebnis bei der 3-monatigen Nachuntersuchung erzielt wurde, wurde bei der 12-monatigen Nachuntersuchung eine leichte Verschlechterung festgestellt. Im Vergleich zu den präoperativen Scores wurde jedoch ein signifikanter Nutzen festgestellt. 28/31 Patienten (93,3%) berichteten bei der Nachuntersuchung nach 12 Monaten über geringere Schmerzen und waren mit dem Verfahren zufrieden. Älteres Alter und psychiatrische Vorerkrankungen wurden als potenzielle Risikofaktoren identifiziert, die mit einem schlechteren Ergebnis einhergehen. Postoperative Komplikationen wie Hämatome, eine Sensibilitätsstörung und eine vorübergehende Muskelschwäche der unteren Extremitäten wurden selten beobachtet.Die endoskopische Facettengelenkdenervation zeigte eine signifikante Verbesserung der klinischen Ergebnisse und der VRS im Vergleich zu den präoperativen Werten von Patienten mit einer mindestens 12 Monate bestehenden chronischen Kreuzschmerzen vor der Operation. Ältere Patienten und Patienten mit psychiatrischen Vorerkrankungen profitieren weniger von dem Eingriff.

Beyond the Evidence: Psychological and Institutional Factors Shaping Patent Ductus Arteriosus Stent Adoption

In infants with ductal dependent pulmonary blood flow (DDPBF), clinicians face a critical choice between two interventions to secure stable pulmonary circulation: the Blalock-Taussig-Thomas (BTT) shunt and patent ductus arteriosus (PDA) stenting. While the BTT shunt has long been the standard palliative procedure, its risks have prompted interest in less invasive alternatives. This manuscript explores the psychological and institutional factors contributing to the growing preference for PDA stenting over surgical shunting in the management of DDPBF. Cognitive biases, public reporting of surgical outcomes, and family preferences significantly influence clinicians' procedural decisions. Understanding these influences is essential to align clinical decisions with evidence-based practices, ensuring optimal care for patients while maintaining transparency and equity in procedural evaluation.

The need for thoracic magnetic resonance imaging before vertebral augmentation surgery in patients with lumbar vertebral fractures

BACKGROUND

Osteoporotic vertebral compression fractures (OVCFs) of the lumbar region may be accompanied by thoracic fractures. Treating only the lumbar fractures can lead to worsening of the thoracic fractures or unresolved postoperative symptoms. This study aims to investigate the need to perform thoracic MRI before vertebral augmentation (including percutaneous vertebroplasty and percutaneous kyphoplasty) in patients with lumbar OVCF.

METHODS

This study retrospectively analyzed patients with lumbar OVCF who were scheduled for surgical treatment. All patients underwent thoracic and lumbar MRI before surgery. We evaluated the proportion of thoracic fractures accompanying lumbar fractures at each segment and identified the common locations of these accompanying fractures. Univariate and multivariate analyses were conducted to determine the risk factors and optimal thresholds for predicting accompanying thoracic fractures.

RESULTS

The study recruited 700 patients, of whom 96 (13.71%) had new thoracic fractures along with lumbar fractures. The most common thoracic segments affected were T10 (22.50%), T9 (19.17%), T8 (26.67%), and T7 (20.83%). Univariate analysis showed significant differences in age and cause of injury between the thoracic fracture group and the control group. The bone density of the thoracic fracture group was significantly lower than that of the control group. Multivariate logistic regression analysis indicated that lifting heavy objects, sprains, and low bone density are risk factors for thoracic fractures in patients with lumbar OVCF.

CONCLUSION

It is crucial to perform thoracic MRI before surgery in patients with lumbar OVCF. This helps to avoid missing thoracic fractures, prevent the worsening of injuries, and ensure better postoperative outcomes.

Appropriate Use Criteria for Osteoporotic Compression Fractures

BACKGROUND CONTEXT

There is a lack of consensus regarding optimal indications for treatment of patients with osteoporotic vertebral fractures. An opportunity exists to improve outcomes if these indications can be clarified.

PURPOSE

The purpose of the North American Spine Society (NASS) Appropriate Use Criteria (AUC) was to determine the appropriate (i.e. reasonable) multidisciplinary treatment recommendations for patients with osteoporotic vertebral fractures across a spectrum of more common clinical scenarios.

STUDY DESIGN

A Modified Delphi process.

PATIENT SAMPLE

Modified consensus based guideline OUTCOME MEASURES: Final rating for treatment recommendations as either "Appropriate", "Uncertain", or "Rarely Appropriate" based on the median final rating among the raters.

METHODS

The methodology was based on the AUC development process established by the Research AND Development (RAND) Corporation. The topic of osteoporotic vertebral compression fracture was selected by NASS for its Clinical Practice Guideline development (CPG). In conjunction, the AUC committee determined key modifiers and adapted the standard definitions developed by the CPG with minimal modifications. A literature search and evidence analysis performed by the CPG were reviewed by the AUC work group. A separate multidisciplinary rating group was assembled. Clinical scenarios were generated based on a matrix of the modifiers, to rate the appropriateness of medical management, cement augmentation, or surgery. Based on the literature, provider experience, and group discussion, each scenario was scored on a nine-point scale on two separate occasions: once without discussion and again following discussion of the initial responses. The median rating for each scenario and level of agreement was then used to determine final indications as rarely appropriate with agreement (1 - 3), uncertain or disagreement (4-6), or appropriate with agreement (7-9). Consensus was not mandatory.

RESULTS

Medical management was appropriate across all scenarios. Cement augmentation was rarely appropriate in 60% of scenarios and uncertain or disagreement in 35% of scenarios. In the 5% of scenarios rated as appropriate with agreement for cement augmentation, high pain scores, acute duration, and simple fracture pattern were always present. Surgery was appropriate in 35% of scenarios and strongly influenced by instability and stenosis with neurological findings. Surgery was rarely appropriate in 18%, and uncertain or disagreement in 47% of scenarios.

CONCLUSIONS

Multidisciplinary appropriate treatment criteria for osteoporotic vertebral fractures were generated based on the RAND methodology. This document provides comprehensive evidence-based recommendations for evaluation and treatment of osteoporotic vertebral fractures. The document in its entirety will be found on the NASS website (https://www.spine.org/Research-Clinical-Care/Quality-Improvement/Appropriate-Use-Criteria).

Shorter Telomere Length Is Associated With Older Age, Poor Sleep Hygiene, and Orthopedic Injury, but Not Mild Traumatic Brain Injury, in a Cohort of Canadian Children

BACKGROUND

Predicting recovery following pediatric mild traumatic brain injury (mTBI) remains challenging. The identification of objective biomarkers for prognostic purposes could improve clinical outcomes. Telomere length (TL) has previously been used as a prognostic marker of cellular health in the context of mTBI and other neurobiological conditions. While psychosocial and environmental factors are associated with recovery outcomes following pediatric mTBI, the relationship between these factors and TL has not been investigated. This study sought to examine the relationships between TL and psychosocial and environmental factors, in a cohort of Canadian children with mTBI or orthopedic injury (OI).

METHODS

Saliva was collected at a postacute (median 7 days) timepoint following injury to assess TL from a prospective longitudinal cohort of children aged 8 to 17 years with either mTBI (n = 202) or OI (n = 90), recruited from 3 Canadian sites. Questionnaires regarding psychosocial and environmental factors were obtained at a postacute follow-up visit and injury outcomes were assessed at a 3-month visit. Univariable associations between TL and psychosocial, environmental, and outcome variables were assessed using Spearman's correlation. Further adjusted analyses of these associations were performed by including injury group, age, sex, and site as covariates in multivariable generalized linear models with a Poisson family, log link function, and robust variance estimates.

RESULTS

After adjusting for age, sex, and site, TL in participants with OI was 7% shorter than those with mTBI (adjusted mean ratio = 0.93; 95% confidence interval, 0.89-0.98; P = .003). As expected, increasing age was negatively associated with TL (Spearman's r = -0.14, P = .016). Sleep hygiene at 3 months was positively associated with TL (adjusted mean ratio = 1.010; 95% confidence interval, 1.001-1.020; P = .039).

CONCLUSION

The relationships between TL and psychosocial and environmental factors in pediatric mTBI and OI are complex. TL may provide information regarding sleep quality in children recovering from mTBI or OI; however, further investigation into TL biomarker validity should employ a noninjured comparison group.

Update on Dupuytren Disease: Pathogenesis, Natural History, Treatment, and Outcomes

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the current molecular biology of Dupuytren disease. 2. Critically evaluate the functional outcomes of treatment. 3. Confidently use any of the commonly used treatments. 4. Provide patients with appropriately selected treatment choices.

SUMMARY

Dupuytren disease is a fibroproliferative disease of the palmar fascia that results in debilitating digital contractures. Despite medical advances, the measurement of disease severity, functional deficits, and treatment outcomes remains challenging. Treatment options vary widely, yet practitioners often use only a small number of modalities. These options range from minimally invasive office procedures to extensive surgery, with adjuncts such as radiation and soft-tissue flaps. A thorough understanding of disease pathophysiology and treatment options can help surgeons offer more individualized care for this elusive disease.

Has the documentation of chest injuries and the development of systemic complications in patients with long bone fractures changed over time?-A systematic literature review and meta-analysis by the IMPACT expert group

INTRODUCTION

Blunt chest trauma represents a major risk factor for complications in polytrauma patients. Various scoring systems have emerged, but their impact is not fully appreciated. This review evaluates changes in chest trauma scoring over time and potential shifts in complication rates linked to modified surgical approaches in long bone fractures.

METHODS

A systematic review was performed utilizing Medline and EMBASE. Included studies analyzed the clinical course following blunt chest trauma with orthopedic injuries requiring surgical fixation. Quantification of chest injury severity was assessed based on the utilized scores in the respective publication such as the Abbreviated Injury Scale, Injury Severity Score, Thoracic Trauma Score (TTS) or the Chest Trauma Score (CTS). The studies were categorized into two groups: "ante-millenium" (AM) (<31.12.2000) and "post-millenium" (PM) (>01.01.2000). Endpoint analysis focused on chest-injury-related complications, including acute respiratory distress syndrome (ARDS), pneumonia, multiple organ failure (MOF), and pulmonary embolism. A meta-analysis examined the influence of surgical timing (early vs. late) on clinical outcomes.

RESULTS

Of 9,682 studies on chest trauma, 20 (4,079 patients) met the inclusion criteria. Most studies in both AM and PM reported the thoracic AIS scale for severity assessment. In group PM more clinical parameters were included in the decision making. Incidences of pooled and weighted mortality were higher in AM (5.1 %) compared to PM (2.3 %, p = 0.003), and ARDS incidence was also greater in AM (12.1 %) versus PM (8.9 %, p = 0.045), though these findings were not confirmed through indirect meta-analysis. Early fracture fixation (<24 h) displayed a non-significant trend toward lower ARDS (OR: 0.60; 95 % CI, 0.23-1.52) and mortality (OR: 0.66; 95 % CI, 0.28-1.55), but significantly reduced pneumonia risk (OR, 0.53; 95 % CI, 0.40-0.71).

CONCLUSION

Prior to 2000, chest injuries were quantified using the AIS alone, while afterwards multiple scoring systems that incorporated pathophysiologic response were utilized. Possibly related to changes in timing of surgery, fixation techniques, or general improvements in-patient care seems to have improved in patients with concomitant thoracic trauma regarding mortality and ARDS. Overall, polytrauma patients with concomitant thoracic injuries might benefit from early definitive fracture care if their physiology and overall injury pattern allows it.

LEVEL OF EVIDENCE

Systematic Review; Level IV.

Racial disparities persist in mortality after firearm assault injuries: A national analysis of the Trauma Quality Improvement Program database

OBJECTIVES

It is unclear whether improvements in the delivery of trauma care over the last decade have diminished racial disparities in mortality after firearm injuries.

METHODS

The American College of Surgeons Trauma Quality Improvement Program was queried for patients (≥18 years old) who experienced penetrating firearm assault injuries between 2008 and 2018. Multivariable logistic regression was used to assess the association between mortality and race, controlling for demographics, comorbidities, shock index, injury severity score injury location, and hospital characteristics.

RESULTS

This retrospective cohort study included 261,116 patients who experienced firearm injuries secondary to assault between 2008 and 2018. Patients most frequently identified as Black (64.1%, n = 167,494), followed by White (16.3%, n = 42,649), Hispanic/Latino (15.7%, n = 41,044), and other racial groups (3.8%, n = 9,929). On multivariable logistic regression, Black patients (odds ratio, 1.53; 95% confidence interval, 1.45-1.62), and Hispanic/Latino patients (odds ratio, 1.11; 95% confidence interval, 1.03-1.19) were more likely to die after a firearm assault injury than White patients. Black patients were more likely to die in the emergency department (62.2%, n = 13,438) compared with White patients (52.7%, n = 2,838), Hispanic/Latino patients (53.0%, n = 2,635), and patients of other races (54.8%, n = 681). Across all years of the study period, Black patients had a greater risk-adjusted mortality rate than White patients and Hispanic/Latino patients.

CONCLUSION

Significant racial disparities in mortality after firearm assault continue to persist. Early death within the emergency department appears to be a significant driver of these persistent disparities.

Risk Factors of Failed Conservative Treatment for Adjacent Vertebral Fractures Following Percutaneous Vertebroplasty

STUDY DESIGN

A retrospective, single-center, observational study.

OBJECTIVE

This study investigated the risk factors associated with the failure of conservative treatment for adjacent vertebral fractures (AVFs).

SUMMARY OF BACKGROUND DATA

Adjacent vertebral fractures following vertebroplasty for osteoporotic vertebral compression fractures are not uncommon. Presently, there is a lack of consensus regarding the management of adjacent vertebral fractures.

METHODS

We included patients who developed adjacent vertebral fractures within 2 years post single-level vertebroplasty between January 2013 and December 2020. All patients initially underwent 6 weeks of conservative treatment, including pain medications, bracing, and physical therapy. Surgical intervention was offered to those with intractable back pain due to AVFs. Baseline demographics, AVF characteristics, and radiologic measurements were systematically collected, and sequential univariable and multivariable logistic regression analyses were conducted to explore the risk factors.

RESULTS

Of the 114 patients with a mean age of 78.6 years, 2-thirds (76 patients) tolerated conservative treatment well, whereas 38 required surgical interventions for adjacent vertebral fractures. Both groups demonstrated similar baseline demographics and radiologic parameters regarding AVFs ( P >0.05). The multivariable logistic regression analyses revealed that the development of AVFs later than 6 months post-vertebroplasty and their caudal location to the index vertebroplasty were the independent risk factors of unsuccessful conservative treatment, with odds ratios of 3.57 (95% confidence interval [CI]: 1.14-11.1, P =0.029) and 2.50 (95% CI, 1.09-5.88, P =0.032), respectively.

CONCLUSION

Adjacent vertebral fractures following percutaneous vertebroplasty generally have favorable outcomes under conservative treatment. However, the timing and the relative anatomical location of adjacent vertebral fractures are associated with treatment efficacy. Adjacent vertebral fractures occurring later than 6 months following the initial vertebroplasty or situated in the caudal location to the index vertebroplasty may exhibit reduced responsiveness to conservative treatment. These patients might benefit from a more aggressive therapeutic approach.

LEVEL OF EVIDENCE

3.

Challenges and Research Opportunities for Integrating Quantitative Electroencephalography Into Sports Concussion Rehabilitation

Although concussion management and return to play/learn decision making focuses on reducing symptoms, there is growing interest in objective physiological approaches to treatment. Clinical and technological advancements have aided concussion management; however, the scientific study of the neurophysiology of concussion has not translated into its standard of care. This expert commentary is motivated by novel clinical applications of electroencephalographic-based neurofeedback approaches (eg, quantitative electroencephalography [QEEG]) for treating traumatic brain injury and emerging research interest in its translation for treating concussion. QEEG's low-cost relative to other brain recording/imaging techniques and precedent in clinical and medical care makes it a potential tool for concussion rehabilitation. Although uncommon, licensed and certified clinicians and medical professionals are implementing QEEG neurofeedback for concussion management within their score of practice. These approaches are not widely adopted nor recommended by professional medical societies, likely because of a limited evidence base of well-designed studies with available standard protocols. Thus, the potential efficacy of QEEG neurofeedback for treating persistent symptoms or cognitive dysfunction after sports-related concussion is unknown. This commentary will update the concussion clinician-scientist on the emerging research, techniques, and disagreements pertaining to the translation of QEEG neurofeedback for concussion management, particularly in the treatment of persistent cognitive difficulties. This commentary will also introduce to readers the fundamentals of how the electroencephalogram may be acquired, measured, and implemented during QEEG neurofeedback. An evidence base of supportive findings from well-designed studies, including those that are retrospective, outcomes-based, and, ultimately, placebo/sham-controlled is recommended prior to considering more widespread adoption of QEEG neurofeedback approaches for treating persistent symptoms or cognitive deficits after sports-related concussion. We review the considerable barriers to this research and clinical implementation, and conclude with opportunities for future research, which will be necessary for establishing the quality and efficacy of QEEG neurofeedback for concussion care.

A proposal for computed tomography-based algorithm for the management of radial head and neck fractures: the Proximal and Articular Radial fractures Management (PARMa) classification

Background

Owing to the great variety of fracture patterns and limitations of the standard radiographic investigation, all the already available classification systems for radial head and neck fractures (RHNFs) are limited by a poor-to-moderate degree of intraobserver and interobserver reliability. Although computed tomography (CT) is being increasingly used to better understand the fracture characteristics, a CT-based classification system of RHNFs is still lacking. Therefore, in this agreement study, we aimed to propose a classification system based on two-dimensional and three-dimensional (2D/3D) CT to test the hypothesis that this classification has good intraobserver and interobserver reliability. We have also provided a treatment algorithm.

Methods

Our proposed classification-Proximal and Articular Radial fractures Management (PARMa)-is based on 2D/3D CT imaging. It is divided into four types based on different fractures patterns. The 2D/3D scans of 90 RHNFs were evaluated in a blinded fashion by eight orthopedic and one radiology consultant, according to the proposed classification. The first phase of observation aimed to estimate the interobserver agreement. The second phase involved a new observation, 4 weeks after the first analysis, and estimated the intraobserver reliability. The standard radiographs of these 90 fractures were also evaluated by the same observers, with the same timing and methods, based on the same classification. Cohen's Kappa was applied for intraobserver agreement. Fleiss's Kappa was used both within and among the evaluators. Kendall's coefficient of concordance was employed to determine the strength of association among the appraisers' rankings. Furthermore, Krippendorff's alpha was chosen as an adjunctive analysis to assess between evaluators' agreement.

Results

For the intraobserver agreement, Fleiss' Kappa statistics confirmed the consistency (overall kappa values: 0.70-0.82). Cohen's Kappa statistics aligned with Fleiss' Kappa, with similar kappa values and significant P values (P < .001). For interobserver agreement, Fleiss' Kappa statistics for between appraisers showed moderate-to-substantial agreement, with kappa values ranging from 0.54 to 0.82 for different responses. The results relating to the appraisers' observation of standard radiographs showed that the overall Fleiss' Kappa values for intraobserver agreement ranged from 0.34 to 0.82, whereas Fleiss' Kappa statistics for interobserver agreement ranged from 0.40 to 0.69.

Conclusions

The proposed classification system is expected to be reliable, reproducible, and useful for preoperative planning and surgical management. Both 2D and 3D CT allow the identification of the magnitude and position of displacement and articular surface involvement.

The effectiveness of balloon kyphoplasty compared to conservative treatment for osteoporotic vertebral compression fractures: A systematic review and meta-analysis

Background

Osteoporotic vertebral compression fractures (OVCFs) are a common and often debilitating condition that significantly impacts quality of life and healthcare costs. While conservative treatment is often pursued initially after fracture, some patients experience severe pain refractory to conservative treatment. In these cases, minimally invasive vertebral augmentation procedures like balloon kyphoplasty (BKP) offer an alternative, but the benefits of BKP compared to conservative treatment remain unclear.

Objectives

To evaluate the effectiveness of BKP versus conservative treatment for pain, quality of life, and function in patients with painful OVCFs.

Primary outcome

Pain improvement up to 12 months after BKP.

Secondary outcomes

Functional improvement, adverse events, and vertebral body height restoration.

Methods

This analysis included randomized controlled trials and prospective comparative studies in which at least 100 participants reported pain outcomes following BKP for OVCFs. The risk of bias was assessed using standard tools, and the certainty of the evidence was evaluated using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach.

Results

BKP demonstrated superior pain reduction versus conservative treatment at 1 month (mean difference (MD): 2.32 [-3.65;-0.99], P < 0.001), 3 months (MD: 1.19 [-2.14; -0.24], P = 0.014), 6 months (MD: 1.34 [-2.65; -0.04], P = 0.044), and 12 months (MD: 1.11 [-1.96;-0.26], P = 0.029), with the largest effect observed at 1 month. Disability improvements were significant at 1 month (standardized mean difference (SMD): 1.08 [-1.67; -0.48], P < 0.001) and 3 months (SMD: 0.50 [-0.96; -0.04], P = 0.032), but not at 6 or 12 months. No significant differences were found in the risk for new vertebral compression fractures between both groups (odds ratio (OR): 1.36 [0.51; 3.64], P = 0.54). According to the GRADE system, moderate certainty evidence indicates that BKP provides superior pain relief compared to conservative treatment at all time points from 1 to 12 months.

Conclusion

BKP showed superior pain reduction compared to conservative treatment from 1 to 12 months and improved disability at 1 and 3 months, with moderate certainty evidence.

Post-concussion changes in the N200 and P300 ERPs are associated with cognitive symptoms and performance

PURPOSE

To examine how post-concussion changes to the N200 and P300 event-related potentials (ERPs) are associated with cognitive symptoms and neurocognitive performance.

METHODS

High-density electroencephalography (EEG) was recorded during a Go/No-Go task from 16 young adults within one month after their concussion and 16 matched controls. Participants were also administered the Cognitive-Linguistic Quick Test (CLQT) and self-reported concussion-like symptoms. Mixed analysis of variance models compared the N200/P300 ERPs between concussion and control groups. Nested linear regressions examined associations between the N200/P300 ERPs and CLQT cognitive domains, cognitive symptom clusters, and total concussion symptoms, with particular interest in within-task changes in the N200/P300 ERPs (e.g. habituation).

RESULTS

N200 and P300 ERP amplitudes were associated with individual differences in cognitive outcomes after concussion. For concussion participants only, smaller P300 amplitudes were significantly associated with greater cognitive symptoms. When considering within-task changes in ERPs over repeated trial presentations, reduced habituation of N200 amplitudes was significantly associated with poorer attention and memory CLQT domain scores. Reduced habituation of P300 amplitudes was also associated with greater cognitive symptoms and total symptoms for concussion participants.

CONCLUSION

Within-task changes in ERP dynamics supporting attention and executive control are associated with individual differences in cognitive outcomes after concussion.

Circulating biomarkers and neuroanatomical brain structures differ in older adults with and without post-traumatic stress disorder

The aim of this study was to advance post-traumatic stress disorder (PTSD) understanding in older adults (48-77 years) by determining if circulating cytokines (IL-1β, IL-2, IL-4, IL-6, IL-12p70, IL17A and TNFα), brain-derived neurotrophic factor (BDNF), vascular endothelial growth factor (VEGF-A) and neuroanatomical brain volumes (grey and white matter, hippocampus, and amygdala) significantly differed in those with versus without PTSD. While none of the tested cytokines showed a significant difference, serum BDNF and VEGF-A levels were found to be significantly higher in the PTSD cohort. The assay used for BDNF quantification was important, with differences in general BDNF detected, but not when pro- and mature BDNF were measured specifically. Additionally, BDNF genotyping revealed a significant difference in Val66Met genotype distribution by PTSD diagnosis, with Val66Met carriers generally having lower circulating levels of BDNF compared to their Val66Val counterparts, regardless of PTSD diagnosis. Neuroanatomically, an all-female subset was examined to find total grey and white matter volumes and left and right hippocampal volumes were significantly smaller in those with PTSD. Collectively, these results show that both novel (VEGF-A) and established targets (BDNF and neuroimaging) may serve as useful biomarkers for older adults with PTSD.

A narrative review: Resuscitation of older adults with hemorrhagic shock

BACKGROUND

The increasing population of older adults presents unique challenges in trauma care due to their reduced physiologic reserve compared to younger patients. Trauma-induced hemorrhage remains a leading cause of mortality, yet there is a significant gap in the optimal management of hemodynamically unstable older adults. This review aims to synthesize current literature on resuscitation strategies, coagulopathy, triage, and the impact of timely interventions in older adult trauma patients experiencing hemorrhagic shock.

STUDY DESIGN AND METHODS

A comprehensive narrative review was conducted following PRISMA-Scr guidelines. A systematic literature search was performed using PubMed, Scopus, and Web of Science databases, yielding 380 titles. After removing duplicates, 287 unique articles were screened, of which 120 full-text articles were reviewed. A total of 45 studies met the inclusion criteria and were analyzed. Studies were categorized based on resuscitation protocols (14 studies), coagulopathy management (7 studies), frailty and aging physiology (10 studies), and timing/triage in trauma care (14 studies).

RESULTS

Studies highlight the effectiveness of the shock index (SI) over traditional vital signs for identifying hemodynamic instability in older adults. Balanced transfusion ratios and whole blood resuscitation show potential benefits, though data specific to older adults remain limited. Goal-directed resuscitation protocols improve outcomes by addressing the unique physiological needs of this population. While trauma-induced coagulopathy rates are similar across age groups, older adults frequently present with pre-existing anticoagulation, complicating management. Standardized care pathways, early activation of massive transfusion protocols (MTP), and tailored resuscitation approaches are critical for optimizing care.

DISCUSSION

The growing geriatric trauma population necessitates improved resuscitation strategies tailored to their unique physiological responses. While balanced transfusions and goal-directed protocols have demonstrated efficacy, further research is required to refine these interventions specifically for older adults. Establishing standardized resuscitation guidelines and defining futility criteria will enhance decision-making and improve outcomes for this vulnerable population.

Dysregulation of neutrophil in sepsis: recent insights and advances

Sepsis remains the leading cause of death in intensive care units. Despite newer antimicrobial and supportive therapies, specific treatments are still lacking. Neutrophils are pivotal components of the effector phase of the host immune defense against pathogens and play a crucial role in the control of infections under normal circumstances. In addition to its anti-infective effects, the dysregulation and overactivation of neutrophils may lead to severe inflammation or tissue damage and are potential mechanisms for poor prognosis in sepsis. This review focuses on recent advancements in the understanding of the functional status of neutrophils across various pathological stages of sepsis to explore the mechanisms by which neutrophils participate in sepsis progression and provide insights for the treatment of sepsis by targeting neutrophils.

Examining the epigenetic transmission of risk for chronic pain associated with paternal post-traumatic stress disorder: a focus on veteran populations

Chronic pain is a public health problem that significantly reduces quality of life. Although the aetiology is often unknown, recent evidence suggests that susceptibility can be transmitted intergenerationally, from parent to child. Post-traumatic stress disorder (PTSD) is a debilitating psychological disorder, often associated with chronic pain, that has high prevalence rates in military personnel and Veterans. Therefore, we aimed to characterise the epigenetic mechanisms by which paternal trauma, such as PTSD, is transmitted across generations to confer risk in the next generation, specifically focusing on Veterans where possible. Numerous overlapping neurological pathways are implicated in both PTSD and chronic pain; many of which are susceptible to epigenetic modification, such as DNA methylation, histone modifications, and RNA regulation. Hence, epigenetic changes related to pain perception, inflammation, and neurotransmission may influence an individual's predisposition to chronic pain conditions. We also examine the effects of PTSD on parenting behaviours and discuss how these variations could impact the development of chronic pain in children. We highlight the need for further research regarding the interactions between paternal trauma and epigenetic processes to ultimately generate effective prevention and therapeutic strategies for Veterans who have been affected by PTSD and chronic pain.

Injuries of the Hamstring Tendons: MR Imaging Diagnosis

MR imaging evaluation of hamstring tendons reveals their association with subgluteal posterior hip pain, emphasizing the superiority of MR imaging over ultrasound due to the deep location of the hamstrings. This review encompasses various conditions, including overuse tendinopathy, metabolic disorders, and sports-related injuries prevalent in elite and recreational athletes. Practical MR imaging-guided approaches tailored to clinical needs and therapeutic options are discussed, highlighting MR imaging's crucial role in monitoring postinjury healing. Furthermore, potential residual complications are outlined, underscoring MR imaging's significance in diagnosing, treating, and evaluating hamstring tendon-related ailments comprehensively.

The stent-screw assisted internal fixation (SAIF) technique: A treatment option for OF5, the three-column unstable osteoporotic vertebral fractures - A case series

PURPOSE

The OF5 type of vertebral osteoporotic fracture (AO Spine-DGOU classification) represents a three-column lesion and as such is considered as highly unstable. These lesions, however, tend to affect elderly, frail patients, in whom invasive management options are limited. The stent-screw-assisted internal fixation (SAIF) technique has previously been reported as a minimally invasive treatment for osteoporotic and neoplastic vertebral fractures. Here, we sought to assess the safety and efficacy of the SAIF technique in a retrospective series of patients with thoracic OF5-fractures.

METHODS

Retrospective identification, in a prospectively maintained database, of patients with OF5-fractures treated with SAIF. Intra- and post-operative complications were reported. Clinical outcome using NRS pain scale and Patient's Global Impression of Change (PGIC) and radiological outcome, with local kyphotic angle (LKA) and VB height (VBH) correction were analyzed.

RESULTS

N = 22 consecutive patients were identified. All fractures were located in the thoracic spine. No intra-procedural complications occurred, although hospitalization-related complications did occur in 2 patients (9 %). There was a statistically significant pain reduction on follow-up. VBH restoration range was 0-12 mm (mean 5.5 mm). The mean postoperative LKA correction was 7.5°, which was maintained at last follow-up.

CONCLUSION

The SAIF technique appears to be a viable alternative in the management of OF5-fractures. Although it does not address all elements of OF5 instability, it appears that the stabilisation of the anterior and middle vertebral columns, coupled with the stabilising effect of the ribcage in the hypomobile thoracic spine, are biomechanically sufficient to treat OF5-fractures in this section of the spine.

Body mass index and sleep disorders after moderate-to-severe traumatic brain injury - a national TBI model systems study

OBJECTIVE

To examine the relationship between body mass index (BMI), newly developed sleep disorders and functional outcome after moderate-to-severe traumatic brain injury (msTBI).

METHODS

Retrospective data from the TBI Model Systems National Database was analyzed, focusing on the independent association between BMI, sleep disorder diagnosis, and functional outcome as measured by the Extended Glasgow Outcome Scale (GOSE) at 1-year post-injury. Linear and logistic regression were used.

RESULTS

Out of 2,142 participants, 84% reported no sleep disorder (NSD), 9% reported a sleep disorder before TBI (PreSD), and 7% developed a sleep disorder after TBI (PostSD). Over 50% of participants were overweight or obese. After adjusting for demographic and clinical characteristics, a one-unit increase of BMI at the time of rehabilitation admission was associated with 3.7% higher odds of PostSD (OR [95%CI]: 1.037 [1.007, 1.068], p = 0.015). PostSD was associated with a 53.6% higher chance of unfavorable GOSE compared to NSD (OR [95%CI]: 1.536 [1.069-2.207], p = 0.02) and an 81.7% higher chance compared to PreSD (OR [95% CI]: 1.817 [1.137-2.905], p = 0.01).

CONCLUSION

Being overweight/obese and developing a sleep disorder had adverse effects on functional outcome, emphasizing the importance of addressing sleep and lifestyle factors in post-msTBI rehabilitation.

Preventing confounding in observational studies in orthopedic trauma surgery through expert panels: a systematic review

PURPOSE

Confounding in observational studies can be mitigated by selecting only those patients, in whom equipoise of both treatments is secured by experts' disagreement over optimal therapy.

METHODS

We conducted a systematic review to identify observational studies in the field of orthopedic trauma surgery that utilized expert panels for patient inclusion in order to limit the potential for confounding.

RESULTS

Four studies were identified that used expert panels to select participants based on expert disagreement. Derived from these studies and our own experience, recommendations were made regarding reporting of the size and composition of the expert panel, the information the expert panel receives, criteria for disagreement, selection of patients, and statistical analysis.

CONCLUSION

With this review we aim to provide insight into this study design and to stimulate discussions about the potential of expert panels to control for confounding in studies of medical treatments.

Development and Pilot Implementation of a Theory-Based Cognitive Rehabilitation Protocol for Adults With Chronic Cognitive Complaints After Mild Traumatic Brain Injury

PURPOSE

The aim of this study was to describe the development of and pilot feasibility outcomes for a strategy-based, brief, intensive cognitive rehabilitation intervention delivered to U.S. service members and veterans with mild traumatic brain injury in a recently completed 3-year pragmatic clinical trial: Symptom-Targeted Approach to Rehabilitation for Concussion (STAR-C).

METHOD

To develop STAR-C, we used the Rehabilitation Treatment Specification System to identify core elements and principles from a previous randomized clinical trial of cognitive rehabilitation, and incorporated principles of neuroplasticity (e.g., high-dose spaced practice of personally meaningful tasks), best clinical practices (e.g., client-centered goal setting), health psychology (e.g., a focus on self-efficacy and motivation), and community-based participation research (e.g., the protocol was co-designed by clinicians and researchers). Treatment was based on a resource-allocation theory of everyday cognitive challenges, which predicted that automatic strategy use would reduce cognitive demands of everyday activities and therefore reduce cognitive symptoms. Treatment was delivered by speech-language pathologists (SLPs) and occupational therapists (OTs), using a protocol that included a problem-focused intake questionnaire, manualized treatment, and clinician resources. Therapy was delivered individually in six to 10 virtual or in-person sessions over 3-4 weeks. Therapy focused on desired changes in function, scaled using Goal Attainment Scaling.

RESULTS

Trained SLPs and OTs delivered STAR-C to 53 U.S. service members and veterans, with treatment fidelity > 95%. Participants and clinicians rated STAR-C as acceptable, feasible, and appropriate, and most participants attained and maintained targets.

CONCLUSION

STAR-C appears to be a feasible method for improving everyday cognitive performance and efficacy should be tested in a controlled study.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.28222613.

In the last 10 years, have our polytrauma patients become geriatric? The emergency trauma bay in the context of demographic change

PURPOSE

One of the key challenges trauma centres are currently facing is the management of polytraumata in an ageing population. The aim of this study is to assess the extent to which demographic changes are reflected in the trauma bay population and the impact on geriatric polytrauma patient outcomes.

METHODS

This is a retrospective single-centre cohort study of a level one trauma centre in Germany. The data were collected from the DGU TraumaRegister. All patients exhibiting vital signs who were primarily admitted to the trauma bay were included in the study. Patient characteristics were compared for years 2011 and 2021. Polytrauma was defined as ISS > 15, and patients aged 65 and over were assigned to the geriatric group.

RESULTS

The study included 214 patients. During the study period, there was a significant increase in the mean age of patients (from 47.7 to 55.9 years) and in the proportion of geriatric patients (from 30.37 to 40.51%). Injury severity, as measured by the Injury Severity Score (ISS), also increased significantly. In the entire patient population, the proportion of patients discharged to their place of residence decreased, while the hospital mortality (2011: 9.63%; 2021: 21.52%) increased.

CONCLUSIONS

The ageing trauma bay population presents new challenges for medical staff, because polypharmacy, multiple comorbidities and frailty become more significant in an ageing population. Enhanced interdisciplinary management, particularly between trauma and geriatric specialists, may mitigate rising mortality rates. Geriatric trauma centres or at least more geriatric expertise might be required to improve the treatment and outcome in this changing population.

Sex-Specific Differences in Sepsis Development in Polytrauma Patients Undergoing Stand-Alone Definitive Surgery

Background and Objectives: In the triaging of polytrauma, patients with less severe injuries and lower somatic stress often undergo isolated definitive orthopedic surgery without damage-control procedures. Adverse events, particularly sepsis, should be minimized. We aimed to identify sex-specific predictors for sepsis in polytrauma patients undergoing stand-alone definitive surgery. Materials and Methods: Our institutional trauma database, containing data from 3653 patients between 1996 and 2022, was filtered for polytrauma patients who underwent definitive surgery, were aged ≥16 years, and had an Injury Severity Score (ISS) ≥16. Injury and physiological parameters were documented upon admission, as well as on the first and second days thereafter. Surgical data were also recorded. All factors were evaluated for their association with sepsis development. Results: Among the 276 patients (71.1% male; mean age 45.0 years, 95% confidence interval 42.7-47.2 years; median ISS of 27, interquartile range, 20-34), the rate of sepsis was 13.8% (n = 38), with a higher incidence in males (16.7%; n = 33) than in females (6.8%; n = 5) (p = 0.026). Head and thorax injuries were more common and severe in septic males, with thorax injuries being predictive. Male patients who developed sepsis also had a higher ISS, an increased heart rate (HR), and lower pH at admission, with ISS and HR being predictive of sepsis. On the first day post-admission, septic males showed higher Base Excess and lower Prothrombin Time. Lactate levels were elevated on both the first and second days post-admission. Surgical predictors for males included less primary extremity surgeries and later secondary spine surgeries. Conclusions: Sepsis is more common in males undergoing stand-alone definitive surgery. Several factors, particularly acidosis and coagulopathy, are associated with this phenomenon. Fewer primary extremity surgeries and delayed secondary spine surgeries were also linked to a higher sepsis risk in males. These findings may help identify patients eligible for stand-alone definitive surgery and underscore the need for more data on female polytrauma patients.

Sex differences in the time trends of sepsis biomarkers following polytrauma

Sepsis is a major cause of death in polytrauma patients, with delayed antibiotics increasing mortality. Although biological sex influences immune function and disease outcomes, gender-specific differences in inflammatory response and sepsis progression remain underexplored. This study examined the time-dependent behavior of C-reactive protein (CRP), procalcitonin (PCT), and white blood cell count (WBC) in male and female polytrauma patients to evaluate their predictive value for sepsis. Additionally, it compared infection sources between genders. This retrospective cohort study at University Hospital Zurich included polytrauma patients aged ≥ 16 years with an Injury Severity Score (ISS) ≥ 16 who developed sepsis within 31 days of admission. Patients were grouped by sepsis status and gender. Time-dependent inflammatory markers (CRP, PCT, WBC) were analyzed using the Mann-Whitney U-test and binary logistic regression. The Closest Top-Left Threshold Method determined time-specific sepsis thresholds. The study included 3059 polytrauma patients (26% females, 74% males), with a median age of 43 and a median ISS of 27. CRP levels were higher in sepsis cases from 24 h in females and 48 h in males, peaking at 122.5 mmol/L (females, 4 days) and 136.5 mmol/L (males, 48 h). PCT differences were significant only in males from 12 h, with a threshold of 1.55 µg/L. WBC levels became significant from day 3 in males and day 4 in females, peaking at 12.82 counts/µL (males) and 13.16 counts/µL (females) on day 10. Pneumonia was the most common infection (70% males, 65% females). Females had more wound infections (27% vs. 18%, p = 0.042) and borderline higher urinary tract infections (22% vs. 14%, p = 0.059). CRP and PCT are standard sepsis markers, but PCT's predictive value varies by gender, and women may show different CRP kinetics. Gender-specific differences in inflammatory markers suggest tailored approaches to enhance diagnostic accuracy and improve sepsis management. Further research is needed to evaluate hormonal and genetic influences on immune responses in polytrauma patients.

Exploring the Anti-PANoptosis Mechanism of Dachaihu Decoction Against Sepsis-Induced Acute Lung Injury: Network Pharmacology, Bioinformatics, and Experimental Validation

Background

Dachaihu decoction (DCHD) is a common Chinese medicine formula against sepsis-induced acute lung injury (SALI). PANoptosis is a novel type of programmed cell death. Nevertheless, The mechanisms of DCHD against SALI via anti-PANoptosis remains unknown.

Methods

First, we identified the intersecting targets among DCHD, SALI, and PANoptosis using relevant databases and published literature. Then, protein-protein interaction (PPI) network, molecular docking, and functional enrichment analysis were conducted. In vivo, cecal ligation and puncture (CLP) was used to construct a sepsis mouse model, and the therapeutic effects of DCHD on SALI were evaluated using hematoxylin and eosin (H&E) staining, quantitative real-time PCR (qRT-PCR), and ELISA. Finally, qRT-PCR, immunofluorescence staining, and Western blotting were used to verify the effect of DCHD-containing serum (DCHD-DS) on LPS-induced RAW 264.7 macrophages in vitro.

Results

82 intersecting targets were identified by mapping the targets of DCHD, SALI, and PANoptosis. Enrichment analysis showed that DCHD against SALI via anti-PANoptosis by modulating tumor necrosis factor (TNF), AGE-RAGE, phosphoinositide 3-kinase (PI3K)-AKT, and Toll-like receptor signaling pathways by targeting Casp3, cellular tumor antigen p53 (TP53), B-cell lymphoma 2 (Bcl2), toll-like receptor-4 (TLR4), STAT3, STAT1, RELA, NF-κB1, myeloid cell leukemia-1 (MCL1), JUN, IL-1β, HSP90AA1, Casp9, Casp8, and Bcl2l1. Molecular docking analysis revealed that the key components of DCHD have a high binding affinity to the core targets. In vivo, DCHD improved lung histopathological injury, reduced inflammatory factor expression, and alleviated oxidative stress injury in lung tissues. In vitro, DCHD-DS alleviated cell morphology changes, the release of pro-inflammatory factors, and p65 nucleus aggregation. Furthermore, we verified that DCHD-DS inhibited PANoptosis by downregulating the PI3K/AKT/NF-κB signalling pathway.

Conclusion

DCHD attenuates SALI by inhibiting PANoptosis via control of the PI3K/AKT/NF-κB pathway. Our study provides a solid foundation for investigating the mechanisms of DCHD and its clinical application in the treatment of SALI.

Clinical and magnetic resonance imaging outcome after proximal hamstring tendon repair at mean 3 years follow-up

PURPOSE

The purpose of this study was to assess clinical and radiological outcome in patients after proximal hamstring tendon repair. We hypothesized that there is a significant correlation among subjective clinical outcome and interlimb asymmetries in muscle strength, fatty infiltration, and hamstring volume.

METHODS

This retrospective monocentric case series included patients with surgical repair after proximal hamstring tendon rupture. Clinical outcome was assessed utilizing: Healthy Days Core Module (CDC HRQOL-4), numeric pain rating scale (NRS), modified Harris Hip Score (mHHS), Tegner Activity Scale (TAS), return to pre-injury activity level (RTPA), and patient satisfaction score. Postoperative hamstring strength was measured using a handheld dynamometer and radiological outcome was determined by postoperative magnetic resonance imaging (MRI).

RESULTS

Twenty-seven patients with a mean age of 51.2 (± 12.6) years were available for follow-up at a mean of 41.11 (± 18.4) months. Patients state a mean of 10.6 (± 11.5) days in the unhealthy days (UHD) index and 88.9% show "good health" in the simple summary score (SSS). Mean subjective outcome scores were as follows: NRS 1.1 (± 2.4), mHHS 90.3 (± 14.8) and TAS 5.7 (± 2.2). A total of 59.3% RTPA and 88.9% state to be somewhat or very satisfied with their surgery. Mean interlimb strength ratio was 0.88 (± 0.21). MRI demonstrated a fully restored muscle-tendon unit, significantly greater fatty infiltration in the injured hamstrings (p = 0.009, d = 0.558), and a mean interlimb hamstring volume ratio of 0.94 (± 0.11). With respect to the 10% benchmark, patients had no significant asymmetries in muscle strength (p = 0.677, d = 0.084) or hamstring volume (p = 0.102, d = - 0.34). Correlation analysis revealed moderate correlation among asymmetries in strength and volume (p = 0.073, r = 0.373). In patients with the operated side inferior to the healthy side (n = 15), there was strong correlation among asymmetries in strength and volume (p = 0.002, r = 0.725). Statistically significant correlation was found between interlimb muscle volume atrophy and increase in fatty infiltration (p = 0.015, r = 0.481).

CONCLUSION

Proximal hamstring repair results in good clinical outcome with satisfactory recovery of hamstring strength and volume. Interlimb asymmetries, in terms of muscle strength, fatty infiltration, and hamstring volume do not correlate with clinical outcome.

STUDY TYPE

Retrospective cohort study; Level of evidence, 3.

Mobility and living status at discharge and after three-months for extramedullary versus intramedullary fixation of AO type 31-A1 trochanteric fractures; an analysis of Dutch hip fracture audit data

PURPOSE

The use of intramedullary fixation of AO type 31-A1 fractures is rising, despite evidence of non-superiority when compared with extramedullary fixation. The aim of this study was to evaluate mobility and living status for extramedullary fixation (EMF) versus intramedullary fixation (IMF) in Dutch hospitals during the initial hospital stay and until three-months after trauma.

METHODS

Data on patient characteristics, mobility, living status, complications, reoperation, and mortality were extracted from the Dutch Hip Fracture Audit Indicator Taskforce. Data were collected for patients (> 65 years) at baseline, at discharge, and at three-months follow-up. Univariate analysis was used for comparing the EMF versus IMF group.

RESULTS

A total of 836 patients were included; 138 (16%) were treated with EMF and 698 (84%) with IMF. No significant differences were found between groups for the overall complication rate during the initial hospital stay (EMF: n = 55 (40%) versus IMF: n = 270 (39%)). Patients treated with EMF showed better mobility at discharge (mobility with frame/2 supports or better, EMF 77% versus IMF 50%), but otherwise no significant difference was found after a three-month follow-up (EMF 80% versus IMF 82%), suggesting faster improved mobility for IMF. However, matched subgroup analysis showed no meaningful differences in rates of deteriorated mobility or living status after three months.

CONCLUSION

This study showed no meaningful differences between EMF and IMF of type 31-A1 trochanteric fractures during hospital stay and until three-month follow-up. Despite little differences in outcome and EMF being the treatment option of first choice by the Dutch Hip fracture guideline, IMF is used in the vast majority of patients.

Between Consecutive Fractures: Time and Sex as Dominant Factors in Type and Severity Concordance of Contralateral Hip Injuries

Background/Objectives: Hip fractures present a global public health concern, with a forecasted rise in incidence and having associated increased mortality rates. This study aimed to investigate whether the AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification of a first hip fracture can predict the location and severity of a subsequent contralateral fracture. Methods: We retrospectively evaluated patients with non-simultaneous bilateral hip fractures between January 2000 and February 2021 and analyzed the type and severity of each fracture using the AO/OTA classification system, interval between fractures (TI), and patients' characteristics, including sex, age at time of each fracture, and radiographic measurements of hip morphology. Results: The study included 182 fractures in 91 patients (68% women, mean age: 79.5 and 82.2 years at first and second fractures, respectively; mean TI: 975 days). A strong association (lambda = 0.437, p < 0.001) was demonstrated between the first and second fracture classifications, which was higher in men (lambda = 0.60, p < 0.001) and for TI < 3 years (lambda = 0.625-0.688, p < 0.001). The mean TI was significantly shorter between the first and subsequent identical fractures than between different fracture types. However, mean hip morphological features did not significantly differ between groups. Conclusions: The initial hip fracture classification significantly predicted the type and severity of a subsequent contralateral fracture, particularly within 3 years and in men. Providing appropriate patient guidance and preventive measures is crucial, particularly for those with primary fractures that are associated with higher morbidity and mortality. Specific fracture-focused interventions, such as preventive intramedullary nail fixation, should be considered.

Sleep and circadian rhythms after traumatic brain injury

Traumatic brain injury (TBI) is a serious public health concern and is one of the major causes of death and chronic disability in young individuals. Sleep-wake disturbances are among the most persistent and debilitating consequences of TBI and are reported by 50%-70% of TBI patients regardless of TBI severity. Excessive daytime sleepiness, fatigue, hypersomnia, and insomnia are the most common sleep disturbances in TBI patients. Post-TBI sleep-wake disturbances are often associated with pain, anxiety, depression, and posttraumatic stress disorder. They may exacerbate cognitive impairment following TBI, reduce community integration, and delay recovery and return to normal life. Changes in sleep architecture following TBI have been reported in the literature but cannot fully explain the extent and intensity of the sleep-wake disturbances reported by TBI patients. The alteration in the circadian timing system is another factor that may partially account for the presence of post-TBI sleep-wake disturbances. Current literature supports cognitive behavioral therapy and sleep hygiene education, light therapy, and certain pharmacologic interventions for treating sleep disturbances in TBI patients. Due to heterogeneous consequences of TBI, early screening and individualized approaches to treatment must be prioritized to improve sleep in TBI patients and consequently speed up recovery.

A Systematic Literature Review of Trauma Systems: An Operations Management Perspective

Background

Trauma systems provide comprehensive care across various settings, from prehospital services to rehabilitation, integrating clinical and social care aspects. Established in the 1970s, these systems are pivotal yet under-researched in their operational management. This study aims to fill this gap by focussing on the integration of operations management (OM) techniques to enhance the efficiency and effectiveness of trauma systems. By leveraging proven OM strategies from other healthcare sectors, we seek to improve patient outcomes and optimise system performance, addressing a crucial need for innovation in trauma care operations.

Methodology

A systematic literature review was conducted using the PICOTS framework to explore operational aspects of trauma systems across varied settings, from emergency departments to specialised centres. Searches were performed in 5 databases, focussing on articles published from 2006 to 2024. Keywords related to operational research and management targeted both trauma systems and emergency management services. Our method involved identifying, synthesising, and summarising studies to evaluate operational performance, with a specific emphasis on articles that applied operational research/management techniques in trauma care. All eligible articles were critically appraised using 2 quality assessment tools.

Results

Employing Donabedian's framework to analyse the quality of trauma systems through structure, process, and outcome dimensions, our systematic review included 160 studies. Of these, 5 studies discussed the application of the Donabedian evaluation framework to trauma systems, and 14 studies examined structural elements, focussing on the location of healthcare facilities, trauma resource management, and EMS logistics. The 63 studies on process indicators primarily assessed triage procedures, with some exploring the timeliness of trauma care. Meanwhile, the 78 outcome-oriented studies predominantly evaluated mortality rates, alongside a smaller number assessing functional outcomes.

Conclusion

Existing evaluation metrics primarily focussed on triage accuracy and mortality are inadequate. We propose expanding these metrics to include patient length of stay (LOS) and rehabilitation trajectory analyses. There is a critical gap in understanding patient flow management and long-term outcomes, necessitating focussed research on LOS modelling and improved rehabilitation data collection. Addressing these areas is essential for optimising trauma care and improving patient recovery outcomes.

A systematic approach to identify gaps in neuroimmunology: TNF-α and fear learning deficits, a worked example

BACKGROUND

The pathophysiology of several neurodegenerative and neuropsychiatric disorders is linked to an altered immune system. However, it is often unclear how the immune system specifically affects these disorders since neuroimmune interactions are very complex. In this paper, we introduce an adjusted version of the adverse outcome pathway (AOP) approach from toxicology to the field of neuroimmunology. A review of the effect of TNF-α on fear learning deficits is used as a worked example to demonstrate how an AOP approach can help identify gaps of knowledge and crucial steps in the pathophysiology of neuroimmunological disorders.

METHODS

The AOP was constructed in five steps. First, the adverse outcome was formulated clearly and specifically. Second, the link between the molecular initiating event and the adverse outcome was established with a preliminary literature search in the Medline database. Third, a systematic literature search was performed in which we identified 95 relevant articles. Fourth, the main biological processes and relevant key events were identified. Fifth, the links between key events were determined and an AOP network was constructed.

RESULTS

We identified three pathways through which TNF-α may affect fear learning. First, TNF-α receptor activation increases NF-κB levels which increases oxidative stress levels and reduces the activity of glutamate transporters. This alters the synaptic plasticity which is associated with impaired fear acquisition, consolidation, and fear extinction. Second, activation of TNF-α receptors increases the expression and capacity of the serotonin transporter which is linked to impaired fear acquisition, expression, and extinction. Third, TNF-α receptor 1 activation can induce necroptosis, leading to neuroinflammation which is linked to fear learning deficits.

CONCLUSION

To successfully apply the AOP approach in neuroimmunology we recommend defining adverse outcomes more precisely, establishing stronger connections between key events from various biological processes, incorporating feedforward and feedback loops, and identifying more mechanistic knowledge in later key events. These adjustments are needed to map the complex processes within the field of neuroimmunology and to identify gaps of knowledge.

Enhanced Safety and Efficacy of O-Arm Navigation Over C-Arm Guidance in Percutaneous Kyphoplasty for Patients With Osteoporotic Vertebral Compression Fractures and Spinal Deformity: A Comparative Study

OBJECTIVE

Although percutaneous kyphoplasty (PKP) under C-arm guidance is an effective treatment for osteoporotic vertebral compression fractures (OVCF), obtaining high-definition images in patients with OVCF and spinal deformities can be challenging or insufficient using traditional C-arm guidance, prompting our institution to adopt the O-arm navigation system-which offers comprehensive 3D imaging and precise navigation-and this study compares its safety and efficacy with conventional C-arm-assisted PKP.

METHODS

This was a retrospective study. From February 2019 to February 2022, we enrolled 28 patients with OVCF (44 vertebrae) with spinal deformity treated with O-arm navigation-assisted PKP and 30 patients with OVCF (42 vertebrae) with spinal deformity treated with C-arm-guided PKP. We recorded puncture times, single-segment operation time, number of cases with bone cement leakage, and length of stay. The visual analog scales (VASs), Oswestry disability indexes (ODIs), recovery of Cobbs angle, and vertebral height were used to assess treatment effect before the operation, on the first day postoperation, the first month postoperation, and at the final follow-up. The chi-squared test was utilized for comparing discrete variables, an independent samples t-test was used for continuous variables, and Pearson's chi-squared test and Fisher's exact test were applied for categorical data.

RESULTS

Demographic features were comparable between the groups. The O-arm navigation group showed a significant reduction in puncture adjustment per vertebrae, single-segment operation time, and the rate of trocar needle malposition compared to the C-arm guidance group. The rate of cement leakage was decreased in the O-arm-guided PKP group, and other complications did not differ between the two groups. Intragroup comparisons revealed significant improvements in VAS scores and ODI on the first day, first month, and final follow-up after the operation (p < 0.05). The VAS score was significantly lower in the O-arm navigation-assisted PKP group than in the C-arm-guided PKP group on the first day postoperatively (p = 0.049). However, no significant differences in VAS scores were observed between the groups at the first month postoperatively or at the final follow-up. In each follow-up period, there was no significant difference in ODI, Cobb angle, and the percent of anterior vertebral height (AVH %) between the groups.

CONCLUSION

O-arm navigation-assisted PKP demonstrates better clinical safety and efficacy than C-arm-guided PKP, marking it as a minimally invasive, safe, and effective procedure for treating patients with OVCF with spinal deformity.

Effects of Blast- and Impact-Related Concussion on Persistent Sleep Problems

OBJECTIVE

Examine whether concussion mechanism of injury (high-level blast [HLB] vs impact) affects the likelihood of persistent sleep problems in a post-deployment military population.

SETTING

Post-Deployment Health Assessment and Re-Assessment survey records completed upon return from deployment and approximately 6 months later.

PARTICIPANTS

Active duty enlisted US Marines who completed both assessments ( N = 64 464).

DESIGN

This retrospective cohort study investigated US Marines deployed between 2008 and 2012. Logistic regression was used to examine persistent sleep problems 6 months after return from deployment.

MAIN MEASURES

Self-reported sleep problems at reassessment were investigated as the outcome. Predictors included HLB-induced concussions (mbTBI vs none), impact-induced concussions (miTBI vs none), occupational risk of low-level blast, probable posttraumatic stress disorder (PTSD), depression, alcohol misuse, sleep problems upon deployment return, and relevant interactions, adjusting for sex and pay grade.

RESULTS

With the exception of sex, all main effects in the model were associated with greater likelihood of reporting persistent sleep problems at reassessment. Sleep problems at return from deployment showed the strongest associations with likelihood of reporting sleep problems at reassessment, followed by mbTBI. The latter was exacerbated by PTSD and depression.

CONCLUSION

mbTBI (vs miTBI) may be more strongly associated with persistent sleep issues that warrant additional monitoring and treatment, particularly among those with probable PTSD and/or depression.

Real-world rates and risk factors for subsequent treatment with vertebroplasty or balloon kyphoplasty after initial vertebral augmentation: a retrospective cohort study

The purpose of this study was to determine the real-world incidence and predictors of additional vertebroplasty or balloon kyphoplasty after initial vertebral augmentation, as a proxy for subsequent symptomatic vertebral fracture. Of patients, 15.5% underwent subsequent vertebral augmentation. The patient's comorbidities are strongly associated with risk of subsequent treatment.

PURPOSE

To determine the real-world incidence and predictors of additional vertebroplasty or balloon kyphoplasty after initial vertebral augmentation, as a proxy for subsequent symptomatic and disabling vertebral fracture.

METHODS

We conducted a retrospective cohort study using commercial insurance claims data (Optum's de-identified Clinformatics® Data Mart Database). Adult patients who underwent subsequent treatment for vertebral fracture within 24 months of initial balloon kyphoplasty (BKP) or vertebroplasty (VP) were classified into "subsequent treatment" or "no subsequent treatment" cohorts. Survival analysis was applied to investigate the effect of risk factors on subsequent treatment.

RESULTS

Between 1 January 2008 and 30 June 2020, a total of 32,513 adult patients underwent a BKP/VP procedure following a diagnosis of vertebral compression fracture in the preceding 12 months. Five thousand thirty-five patients (15.5%) underwent a subsequent BKP/VP treatment within 2 years; 90% had a single fracture level treated. An increased hazard of subsequent treatment was associated with a number of fractures treated at initial BKP/VP (≥ 4 levels, adjusted hazard ratio (AHR) 1.68 (95% CI 1.24-2.26); steroid use, AHR 1.9 (95% CI 1.31-1.48); Elixhauser Comorbidity Index ≥ 4, AHR 1.44 (95% CI 1.17-1.77); and multiple myeloma, AHR 1.31 (95% CI 1.13-1.53)). Age < 70 years was associated with reduced hazard of subsequent treatment (AHR 0.81, 95% CI 0.74-0.89).

CONCLUSIONS

One in seven patients underwent subsequent treatment for vertebral fracture after initial vertebral augmentation. Baseline patient characteristics were associated with increased risk of subsequent fracture within 2 years, suggesting that a patient's natural history is strongly associated with risk of subsequent treatment rather than the initial surgical procedure itself.

Relationship Between Structural and Functional Network Connectivity Changes for Patients With Traumatic Brain Injury and Chronic Health Symptoms

Combination of structural and functional brain connectivity methods provides a more complete and effective avenue into the investigation of cortical network responses to traumatic brain injury (TBI) and subtle alterations in brain connectivity associated with TBI. Structural connectivity (SC) can be measured using diffusion tensor imaging to evaluate white matter integrity, whereas functional connectivity (FC) can be studied by examining functional correlations within or between functional networks. In this study, the alterations of SC and FC were assessed for TBI patients, with and without chronic symptoms (TBIcs/TBIncs), compared with a healthy control group (CG). The correlation between global SC and FC was significantly increased for both TBI groups compared with CG. SC was significantly lower in the TBIcs group compared with CG, and FC changes were seen in the TBIncs group compared with CG. When comparing TBI groups, FC differences were observed in the TBIcs group compared with the TBIncs group. These observations show that the presence of chronic symptoms is associated with a distinct pattern of SC and FC changes including the atrophy of the SC and a mixture of functional hypoconnectivity and hyperconnectivity, as well as loss of segregation of functional networks.

Scanning the aged to minimize missed injury: An Eastern Association for the Surgery of Trauma multicenter study

BACKGROUND

Despite the high incidence of blunt trauma in older adults, there is a lack of evidence-based guidance for computed tomography (CT) imaging in this population. We aimed to identify an algorithm to guide use of a pan-scan (head/cervical spine [C-spine]/torso) or a selective scan (head/C-spine ± torso). We hypothesized that a patient's initial history and examination could be used to guide imaging.

METHODS

We prospectively studied blunt trauma patients 65 years or older at 18 Level I/II trauma centers. Patients presenting >24 hours after injury or who died upon arrival were excluded. We collected history and physical elements and final injury diagnoses. Injury diagnoses were categorized into CT body regions of head/C-spine or Torso (chest, abdomen/pelvis, and thoracolumbar spine). Using machine learning and regression modeling as well as a priori clinical algorithms based, we tested various decision rules against our data set. Our priority was to identify a simple rule, which could be applied at the bedside, maximizing sensitivity and negative predictive value (NPV) to minimize missed injuries.

RESULTS

We enrolled 5,498 patients with 3,082 injuries. Nearly half (n = 2,587 [47.1%]) had an injury within the defined CT body regions. No rule to guide a pan-scan could be identified with suitable sensitivity/NPV for clinical use. A clinical algorithm to identify patients for pan-scan, using a combination of physical examination findings and specific high-risk criteria, was identified and had a sensitivity of 0.94 and NPV of 0.86. This rule would have identified injuries in all but 90 patients (1.6%) and would theoretically spare 11.9% (655) of blunt trauma patients a torso CT.

CONCLUSION

Our findings advocate for head/C-spine CT in all geriatric patients with the addition of torso CT in the setting of positive clinical findings and high-risk criteria. Prospective validation of this rule could lead to streamlined diagnostic care of this growing trauma population.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level II.