Traumatic atlantooccipital dislocation: comprehensive assessment of mortality, neurologic improvement, and patient-reported outcomes at a Level 1 trauma center over 15 years

BACKGROUND CONTEXT

Only Level 3 evidence exists for the diagnosis and treatment of atlantooccipital dislocation (AOD) with few studies examining mortality, neurologic improvement, and patient-reported outcomes (PROs).

PURPOSE

First, the aim was to determine: the incidence of AOD, 90-day surgical morbidity and mortality after AOD, patient factors that may be associated with delayed or missed diagnosis, and factors that were associated with mortality and neurologic improvement after AOD. Secondly, the aim was to quantify the pain, disability, and quality of life experienced by patients surviving AOD.

STUDY DESIGN/SETTING

This was a retrospective cohort study.

PATIENT SAMPLE

A total of 5,337 consecutive spine computed tomography traumagrams from 1997 to 2012 were included.

OUTCOME MEASURES

Mortality, neurologic improvement, complications, EuroQol five dimensions (EQ-5D), Neck Disability Index (NDI), Numeric Rating Scale (NRS)-neck, NRS-arm, and return-to-work were the outcome measures.

METHODS

Patients were considered to have AOD if they met one of the following radiographic criteria: basion-dens interval greater than 10 mm; basion-axial interval: anterior displacement greater than 12 mm or posterior displacement greater than 4 mm between the basion and posterior C2 line; and condyle to C1 interval greater than 1.4 mm. Linear regression analysis was performed to identify factors associated with 90-day mortality, neurologic improvement, and missed diagnosis. Patient-reported outcomes were assessed via phone interview.

RESULTS

Thirty-one patients met radiographic criteria for AOD; an incidence of 0.6% over 15 years. Twenty-one (68%) patients were treated with occipital cervical fusion. At 90 days postoperatively, there were no new neurologic deficits or reoperations. Eight (26%) patients died within 90 days. All patients who died had no documented AOD diagnosis and were not treated surgically. Missed AOD diagnosis was the strongest predictor of mortality. Younger age, lower Glasgow Coma Score, lower Injury Severity Score (ISS) score, and worse initial American Spinal Injury Association (ASIA) score were significantly associated with greater neurologic improvement. Higher ISS score and better ASIA score were significantly associated with missed AOD diagnosis. The average PROs metrics at time of telephone follow-up were as follows: EQ-5D=0.73±0.19, NDI=30.89±18.57, NRS-neck=2.33±2.21, NRS-arm=2.00±2.54. Of the patients with follow-up data, four were employed full-time, and five were receiving disability.

CONCLUSIONS

Our work suggests that failure to diagnose AOD is a powerful predictor of mortality. Higher ISS scores and better neurologic presentation were significantly associated with missed diagnosis. Craniocervical arthrodesis preserved neurologic function with low complication rate and unexpectedly high PROs and return-to-work. These results must be carefully interpreted because it is unclear whether missed AOD diagnosis accompanies another death-causing injury (eg, traumatic brain injury) or if failure to treat AOD contributes to mortality in a multifactorial manner.

Neonatal outcomes of infants admitted to a large government hospital in Amman, Jordan

OBJECTIVE

To describe characteristics and outcomes of Jordanian newborns admitted to a large governmental neonatal intensive care unit (NICU).

METHODS

Newborns born at the government hospital, Al Bashir, in Amman, Jordan were prospectively enrolled. The study focused on newborns admitted to the NICU and a retrospective chart review was performed. Abstraction included in-hospital mortality, antibiotic days, ventilation, oxygen use, and CRP levels. Rank sum and chi-squared tests were used to compare across outcomes. Logistic regression of hypothesized risk factors with death adjusted for gestational age.

RESULTS

Of the 5,466 neonates enrolled from 2/10-2/11, medical records were available for 321/378(84.9%) infants admitted to the NICU. The median gestational age was 36 weeks, median birth weight was 2.3 kg, and 28(8.7%) infants died. The two most common reasons for admission and mortality were respiratory distress syndrome and prematurity. Low Apgar scores and positive CRP were predictors of mortality. Risk factors associated with increased use of antibiotics, oxygen hood, and mechanical ventilation included lower gestational age and prematurity.

CONCLUSION

Infants admitted to the Jordanian NICU have significantly higher median gestational age and birth weights than in developed countries and were associated with significant morbidity and mortality. Continuations of global efforts to prevent prematurity are needed.

Feasibility and accuracy evaluation of three human papillomavirus assays for FTA card-based sampling: a pilot study in cervical cancer screening

Background

Liquid-state specimen carriers are inadequate for sample transportation in large-scale screening projects in low-resource settings, which necessitates the exploration of novel non-hazardous solid-state alternatives. Studies investigating the feasibility and accuracy of a solid-state human papillomavirus (HPV) sampling medium in combination with different down-stream HPV DNA assays for cervical cancer screening are needed.

Methods

We collected two cervical specimens from 396 women, aged 25–65 years, who were enrolled in a cervical cancer screening trial. One sample was stored using DCM preservative solution and the other was applied to a Whatman Indicating FTA Elute® card (FTA card). All specimens were processed using three HPV testing methods, including Hybrid capture 2 (HC2), careHPV™, and Cobas®4800 tests. All the women underwent a rigorous colposcopic evaluation that included using a microbiopsy protocol.

Results

Compared to the liquid-based carrier, the FTA card demonstrated comparable sensitivity for detecting high grade Cervical Intraepithelial Neoplasia (CIN) using HC2 (91.7 %), careHPV™ (83.3 %), and Cobas®4800 (91.7 %) tests. Moreover, the FTA card showed a higher specificity compared to a liquid-based carrier for HC2 (79.5 % vs. 71.6 %, P = 0.015), comparable specificity for careHPV™ (78.1 % vs. 73.0 %, P > 0.05), but lower specificity for the Cobas®4800 test (62.4 % vs. 69.9 %, P = 0.032). Generally, the FTA card-based sampling medium’s accuracy was comparable with that of liquid-based medium for the three HPV testing assays.

Conclusions

FTA cards are a promising sample carrier for cervical cancer screening. With further optimization, it can be utilized for HPV testing in areas of varying economic development.

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A Deep Learning Model of Histologic Tumor Differentiation as a Prognostic Tool in Hepatocellular Carcinoma

Tumor differentiation represents an important driver of the biological behavior of various forms of cancer. Histologic features of tumor differentiation in hepatocellular carcinoma (HCC) include cytoarchitecture, immunohistochemistry profile, and reticulin framework. In this study, we evaluate the performance of an artificial intelligence (AI)-based model in quantifying features of HCC tumor differentiation and predicting cancer-related outcomes. We developed a supervised AI model using a cloud-based, deep learning platform to quantify histologic features of HCC differentiation, including various morphologic parameters (nuclear density, area, circularity, chromatin pattern, and pleomorphism), mitotic figures, immunohistochemistry markers (HepPar 1 and glypican-3), and reticulin expression. We applied this AI model to patients undergoing HCC curative resection and assessed whether AI-based features added value to standard clinical and pathologic data in predicting HCC-related outcomes. Ninety-nine HCC resection specimens were included. Three AI-based histologic variables were most relevant to HCC prognostic assessment: (1) percentage of tumor occupied by neoplastic nuclei (nuclear area percent), (2) quantitative reticulin expression in the tumor, and (3) HepPar 1 low (ie, expressed in <50% of the tumor)/glypican-3-positive immunophenotype. Statistical models that included these AI-based variables outperformed models with combined clinical pathologic features for overall survival (C-indexes of 0.81 vs 0.68), disease-free survival (C-indexes of 0.73 vs 0.68), metastasis (C-indexes of 0.78 vs 0.65), and local recurrence (C-indexes of 0.72 vs 0.68) for all cases, with similar results in the subgroup analysis of World Health Organization grade 2 HCCs. Our AI model serves as a proof of concept that HCC differentiation can be objectively quantified digitally by assessing a combination of biologically relevant histopathologic features. In addition, several AI-derived features were independently predictive of HCC-related outcomes in our study population, most notably nuclear area percent, hepar-low/glypican-3-negative phenotype, and decreasing levels of reticulin expression, highlighting the relevance of quantitative analysis of tumor differentiation features in this context.

The Dilemma of the Racist Patient

Encounters with racist patients can be distressing, damage the physician-patient relationship, and threaten the collegial environment of the health care setting. Although policies guiding physician interactions may exist, providers may be uncomfortable and left vulnerable in racially charged interactions. When providers deal with racially intolerant patients, a courteous address of their inappropriate behavior is crucial, after which a dialogue should ensue to identify causes of potentially misplaced anger. Unsuccessful attempts at relationship salvage should be further guided by ethics teams, and in cases of a continued impasse, physicians should absolve themselves of medical duties provided that an appropriate alternative provider is available. Although racism in the health care setting can present a reasonable window to generate productive dialogue to improve race relations, a deeply entrenched and pervasive mindset can be difficult to reverse and should not impede the primary goal of providing timely patient care.