The human anti-ganglioside GM1 autoantibody response following traumatic and surgical central nervous system insults.

Predictors of the central nervous system (CNS) directed autoantibody response after acute CNS injury are poorly understood. We analyzed titers of IgG and IgM autoantibodies to ganglioside GM1 in serial serum specimens collected from human patients following acute spinal cord injury (SCI), traumatic brain injury (TBI) and brain tumor resection. We also assessed putative predictors of the autoantibody titers. We enrolled 19 patients with acute SCI, 14 patients with acute severe TBI, and 19 patients undergoing brain tumor resection. We also enrolled 25 control subjects. Some SCI, TBI and tumor patients exhibited elevated IgG titers as compared with control values; some SCI and TBI patients exhibited an acute peak in IgG titers, most commonly 14 days after insult. Some clinical and radiographic measures of injury severity correlated with IgG titer elevation in SCI and TBI patients but not tumor patients. Our study demonstrates that diverse CNS insults are followed by increased IgG autoimmune antibody titers to the CNS antigen ganglioside GM1, however the response inherent to each insult type is unique. IgG autoimmune antibody titers to GM1 merit further study as a biomarker of traumatic injury severity that can be measured in delayed fashion after CNS insult. These human data help to inform which patients with CNS insults are at risk for CNS-directed autoimmunity as well as the time course of the response.

The Effect of Hospital Transfer on Patient Outcomes After Rehabilitation for Spinal Injury.

OBJECTIVE: Spine fractures, including associated spinal cord injury, account for 3%-6% of all skeletal fractures annually in the United States. Patients who undergo interhospital transfer after injury may have a greater likelihood of nonroutine disposition, longer hospital stay, and higher cost. We evaluated the effects of patient transfer on functional outcomes after spine trauma. METHODS: Patients were treated after acute traumatic spine injury at a rehabilitation hospital in 2011-2017. Compared patients were those directly admitted to the tertiary hospital or transferred from a community hospital. RESULTS: A total of 188 patients (mean age 46.1 ± 18.6 years, 77.1% men) were evaluated, including 130 (69.1%) directly admitted and 58 (30.9%) transferred patients. The most common levels of injury were at C5 (19.1%) and C6 (12.2%), and most injuries were American Spinal Injury Association injury severity score grade D (33.2%) or grade A (32.1%). No statistical difference in age, injury pattern, timing from injury to surgery, or rehabilitation length of stay was seen between admitted and transferred patients. A significant improvement in ambulation distances was seen at discharge for directly admitted compared with transferred patients (447.7 ± 724.9 vs. 159.9 ± 359.5 feet; P = 0.005). However, no significant difference primary outcomes, namely American Spinal Injury Association injury severity score distribution (P = 0.2) or Functional Independence Measures (Δ30.9 ± 15.9 vs. 30.1 ± 17.1; P = 0.7), were seen between admitted and transferred patients at time of rehabilitation discharge. CONCLUSIONS: Interhospital transfer status did not diminish time to rehabilitation after injury or reduce functional recovery, suggesting early surgical treatment in community settings may have merit prior to transfer.

Cost Analysis of Inpatient Rehabilitation after Spinal Injury: A Retrospective Cohort Analysis.

Objective The lifetime direct and indirect costs of spinal injury and spinal cord injury (SCI) increase as the severity of injury worsens. Despite the potential for substantial improvement in function with acute rehabilitation, the factors affecting its cost have not yet been evaluated. We used a proprietary hospital database to evaluate the direct costs of rehabilitation after spine injury. Methods A single-center, retrospective cohort cost analysis of patients with acute, traumatic spine injury treated at a tertiary facility from 2011 to 2017 was performed. Results In the 190 patients (mean age 46.1 ± 18.6 years, 76.3% males) identified, American Spinal Injury Association impairment scores on admission were 32.1% A, 14.7% B, 14.7% C, 33.2% D, and 1.1% E. Surgical treatment was performed in 179 (94.2%) cases. Most injuries were in the cervical spine (53.2%). A mean improvement of Functional Impairment Score of 30.7 ± 16.2 was seen after acute rehabilitation. Costs for care comprised facility (86.5%), pharmacy (9.2%), supplies (2.0%), laboratory (1.5%), and imaging (0.8%) categories. Injury level, injury severity, and prior inpatient surgical treatment did not affect the cost of rehabilitation. Higher injury severity (p = 0.0001, one-way ANOVA) and spinal level of injury (p = 0.001, one-way ANOVA) were associated with higher length of rehabilitation stay in univariate analysis. However, length of rehabilitation stay was the strongest independent predictor of higher-than-median cost (risk ratio = 1.56, 95% CI 1.21-2.0, p = 0.001) after adjusting for other factors. Conclusions Spine injury has a high upfront cost of care, with greater need for rehabilitation substantially affecting cost. Improving the efficacy of rehabilitation to reduce length of stay may be effective in reducing cost.

Self-Reported Use and Attitudes Toward Performance-Enhancing Drugs in Ultramarathon Running.

INTRODUCTION: The use of performance enhancing drugs (PEDs) has been reported in several sports. There have been no peer-reviewed articles on the use of PEDs in ultramarathon running. This study was to examine the use of PEDs in ultramarathon running and to identify attitudes and beliefs about the usage of PEDs in the sport. METHODS: An online survey was developed. The survey was distributed to potential participants through Ultrasignup and the Western States Endurance Run Facebook sites. The survey included 9 demographic questions, 11 PED questions, and a previously validated 17-item performance enhancement attitude scale (PEAS). RESULTS: Six hundred nine self-identified ultramarathon runners completed the survey; 8.4% of respondents reported using PEDs during competition or training. Cannabinoids, narcotics, and stimulants were the PEDs that were most frequently reported. There was no difference between sex, age, country of origin, rank, miles/week of training, or longest race between those that reported using PEDs and those that did not report using PEDs. There was, however, a significant difference in athletes who reported they knew another ultramarathon runner who had used PEDs to have significantly higher years of participation and ranked in the top 20th percentile. There additionally was an increased PEAS score of individuals who reported using a PED or individuals that knew an individual who used PEDs. CONCLUSION: PEDs are being used in ultramarathon running. The exact extent of the use of PEDs in ultramarathon running is still unknown and challenging to fully investigate without formal, random testing, which is expensive and technically challenging.

The effect of body mass index on fluoroscopic time and radiation dose during lumbar transforaminal epidural steroid injections.

OBJECTIVE: Transforaminal epidural steroid injections (TFESIs) are a commonly used, effective treatment for radicular pain. Accurate delivery of the injected medication helps to ensure maximum therapeutic efficacy and to decrease possible adverse events, and fluoroscopy is the preferred and most common image-guidance modality used to ensure accurate needle placement during lumbar TFESIs. However, fluoroscopic-guided lumbar TFESIs put patients at risk because of radiation exposure. The purpose of this study was to determine the relationship between body mass index (BMI) and fluoroscopy time and radiation dose during lumbar TFESIs. DESIGN: A retrospective study design was used. SETTING: The study was conducted at an academic orthopedic center. All procedures were performed by physicians board-certified in Physical Medicine and Rehabilitation (PM&R) and with subspecialty certification in sports medicine, or by a trainee under close supervision from an attending physician. PARTICIPANTS: Participants were patients who underwent fluoroscopic-guided lumbar TFESIs between February 2013 and March 2015 with a documented height/weight, fluoroscopy time, and radiation dose. INTERVENTIONS: All patients received unilateral or bilateral lumbar TFESIs with fluoroscopic guidance. Fluoroscopy time and dose were recorded. MAIN OUTCOME MEASURES: The main outcome measures were fluoroscopy time and radiation dose. A Bonferroni correction was implemented for multiple comparisons, defining statistical significance at p<.01. RESULTS: A total of 2,443 injections were performed on 1,548 patients. There were 419 normal, 572 overweight, and 557 obese patients, respectively. There were 1,426 first-time injections and 1,017 repeat injections. Sixty-nine percent (1,681) were unilateral injections, and 26.4% (645) were single level injections. A trainee was involved in 1,361 (55.7%) of the injections performed. The mean fluoroscopy time for all injections was 30.0±17.5 seconds, and the mean radiation dose was 2,164±1,484 mGy-cm(2). The mean fluoroscopy time was 27.7±15.2 seconds for normal weight patients, 30.0±21.0 seconds for overweight patients, and 32.2±15.1 seconds for obese patients, showing a significant difference between groups (p<.001). The mean radiation doses for each group were 1,376±450, 1,911±653, and 3,029±640 mGy-cm(2), respectively, with a significant increase in radiation dose with increasing BMI (p<.001). CONCLUSIONS: The findings of this study demonstrate that fluoroscopy radiation dose and fluoroscopy time during lumbar TFESIs are increased in patients with an elevated BMI, and in patients of greater age, but the presence of a trainee had no effect on fluoroscopy time.

The Effect of Body Mass Index on Fluoroscopic Time and Radiation Dose During Sacroiliac Joint Injections.

BACKGROUND: Sacroiliac joint (SIJ) injections are commonly performed under fluoroscopic guidance. Radiation exposure to patients and providers has not been comprehensively studied, particularly the effect of body mass index (BMI). OBJECTIVE: To identify whether patients with a larger BMI require longer fluoroscopy time or a larger radiation dose during performance of an SIJ injection. DESIGN: Retrospective study of an academic institution database. SETTING: Academic outpatient musculoskeletal clinic. PATIENTS: All patients who underwent SIJ injections during a 10-year period. MAIN OUTCOME MEASUREMENTS: Machine-reported fluoroscopic time and machine-reported radiation dose. A Bonferroni correction was implemented with P ≤ .01 as statistically significant. RESULTS: A total of 453 SIJ injections were performed in 359 patients. No statistically significant differences in fluoroscopy time were found between patients with BMI scores identified as normal, overweight, and obese (P = .054). However, the radiation doses were significantly greater for patients with higher BMI scores (χ(2) [2, n = 441] = 62.4, P < .001); the median (interquartile range) doses were 1210 (839), 1671 (1240), and 2090 (2170) mGy-cm(2) for normal weight, overweight, and obese patients, respectively. Although longer needles were used more often in obese patients (χ(2) [2, n = 452] = 31.5, P < .001), fluoroscopy time was not associated with needle length (P = .162). No relationships were identified between fluoroscopy time and first-time (as opposed to repeat) injection (P = .123), trainee involvement (χ(2) [1, n = 698] = 3.9, P = .049), or age (P = .337). CONCLUSIONS: Patients with an elevated BMI score who are undergoing SIJ injection receive an increased radiation dose despite equivalent fluoroscopic time. This finding suggests that the increased dose is likely due to x-ray output from the fluoroscope traversing a greater tissue mass, as opposed to the physician requiring more fluoroscopic images for proper needle placement. Fortunately, the increased radiation dose delivered to patients with a larger BMI score likely has negligible effects.

Left Hip Pain Caused by Right Hip Osteoarthritis in a Patient With an Incomplete Cervical Spinal Cord Injury: A Case Report.

A 70-year-old woman with a right hemisensory deficit caused by an incomplete cervical spinal cord injury presented with left hip pain. The clinical assessment suggested that her left-sided hip pain was attributable to severe right hip osteoarthritis. Her left hip pain resolved completely after she underwent a right total hip arthroplasty. This case is presented, along with a review of the literature on spinal and supraspinal neuronal reorganization after spinal cord injury. This case report suggests the occurrence of central sensory reorganization after an incomplete cervical spinal cord injury, which resulted in a patient perceiving right hip pathology in her left hip.