Minimally invasive transforaminal lumbar interbody fusion with expandable articulating interbody spacers significantly improves radiographic outcomes compared to static interbody spacers.

BACKGROUND: The goal of minimally invasive transforaminal lumbar interbody fusion (MI TLIF) is to restore and maintain disc height and lordosis until arthrodesis occurs, while minimizing muscle disruption and improving recovery time. The purpose of this study was to compare the radiographic outcomes in patients treated with an articulating expandable spacer in MI TLIF to more traditional static spacers. METHODS: This was a multi-site, multi-surgeon, Institutional Review Board-exempt, retrospective clinical study from a prospectively collected database. It included 48 patients with a diagnosis of degenerative disc disease (DDD) at one level from L2 to S1 with or without Grade 1 spondylolisthesis who underwent MI TLIF using either an articulating expandable or static interbody spacer. Twenty-seven patients were in the banana-shaped articulating expandable interbody spacer (ALTERA®, Globus Medical, Inc., Audubon, PA, USA) group, while 21 patients were in the static interbody spacer group. Both groups had supplemental posterior pedicle screw and rod fixation. Radiographic records were assessed for disc height, neuroforaminal height, and lordosis at baseline, 3 and 6 months, and final follow-up. RESULTS: The articulating expandable spacer group displayed significantly greater improvement in anterior disc height from baseline compared to the static spacer group at 6 weeks, 3 and 6 months, and final follow-up by averages of 2.6 mm (79%), 2.8 mm (92%), 3.4 mm (105%), and 3.8 mm (139%), respectively (P<0.05). Mean increases in posterior disc height were significantly greater in the expandable group compared to the static group by 1.2 mm (65%) and 1.7 mm (104%) at 6 months and final follow-up, respectively (P<0.05). Articulating expandable spacers produced significantly greater average improvement by 4.0 mm in neuroforaminal height from baseline to final follow-up compared to static spacers (P<0.05). Increases in intervertebral angle from baseline were significantly greater in the expandable group than in the static group at 3 and 6 months, and final follow-up by averages of 2.5°, 2.8°, and 3.1°, respectively (P<0.05). The articulating expandable spacer group resulted in significantly greater improvements in lumbar lordosis from baseline to 3 and 6 months than the static spacer group by 4.4° and 4.0°, respectively (P<0.05). CONCLUSIONS: MI TLIF with articulating expandable interbody spacers provides significant restoration and maintenance of disc height, neuroforaminal height, and lordosis compared to static spacers in this comparative cohort. Long-term clinical outcomes are needed to correlate with these radiographic improvements.

Inpatient Urine Cultures Are Frequently Performed Without Urinalysis or Microscopy: Findings From a Large Academic Medical Center.

OBJECTIVE To describe the frequency of urine cultures performed in inpatients without additional testing for pyuria DESIGN Retrospective cohort study SETTING A 1,250-bed academic tertiary referral center PATIENTS Hospitalized adults METHODS This study included urine cultures drawn on 4 medical and 2 surgical wards from 2009 to 2013 and in the medical and surgical intensive care units (ICUs) from 2012 to 2013. Patient and laboratory data were abstracted from the hospital's medical informatics database. We identified catheter-associated urinary tract infections (CAUTIs) in the ICUs by routine infection prevention surveillance. Cultures without urinalysis or urine microscopy were defined as "isolated." The primary outcome was the proportion of isolated urine cultures obtained. We used multivariable logistic regression to assess predictors of isolated cultures. RESULTS During the study period, 14,743 urine cultures were obtained (63.5 cultures per 1,000 patient days) during 11,820 patient admissions. Of these, 2,973 cultures (20.2%) were isolated cultures. Of the 61 CAUTIs identified, 31 (50.8%) were identified by an isolated culture. Predictors for having an isolated culture included male gender (adjusted odds ratio [aOR], 1.22; 95%; confidence interval [CI], 1.11-1.35], urinary catheterization (aOR, 2.15; 95% CI, 1.89-2.46), ICU admission (medical ICU aOR, 1.72; 95% CI, 1.47-2.00; surgical ICU aOR, 1.82; 95% CI, 1.51-2.19), and obtaining the urine culture ≥1 calendar day after admission (1-7 days aOR, 1.91; 95% CI. 1.71-2.12; >7 days after admission aOR, 2.81; 95% CI, 2.37-3.34). CONCLUSIONS Isolated urine cultures are common in hospitalized patients, particularly in patients with urinary catheters and those in ICUs. Interventions targeting inpatient culturing practices may improve the diagnosis of urinary tract infections. Infect Control Hosp Epidemiol 2017;38:455-460.

Decreased Phosphorylated Protein Kinase B (Akt) in Individuals with Autism Associated with High Epidermal Growth Factor Receptor (EGFR) and Low Gamma-Aminobutyric Acid (GABA).

Dysregulation of the PI3K/AKT/mammalian target of rapamycin (mTOR) pathway could contribute to the pathogenesis of autism spectrum disorders. In this study, phosphorylated Akt concentration was measured in 37 autistic children and 12, gender and age similar neurotypical, controls using an enzyme-linked immunosorbent assay. Akt levels were compared to biomarkers known to be associated with epidermal growth factor receptor (EGFR) and c-Met (hepatocyte growth factor (HGF) receptor) pathways and severity levels of 19 autism-related symptoms. We found phosphorylated Akt levels significantly lower in autistic children and low Akt levels correlated with high EGFR and HGF and low gamma-aminobutyric acid, but not other biomarkers. Low Akt levels also correlated significantly with increased severity of receptive language, conversational language, hypotonia, rocking and pacing, and stimming, These results suggest a relationship between decreased phosphorylated Akt and selected symptom severity in autistic children and support the suggestion that the AKT pathways may be associated with the etiology of autism.

Decreased plasma myeloperoxidase associated with probiotic therapy in autistic children.

AIM: To assess plasma myeloperoxidase (MPO) levels in autistic children and to test the hypothesis that there is an association between decreased MPO concentration and probiotic therapy. SUBJECTS AND METHODS: Plasma from 49 autistic children (39 males; mean age 11.4 years) (17 with diagnosed gastrointestinal (GI) disease - chronic diarrhea and/or constipation (10 of these GI patients were taking probiotics) and 26 receiving probiotic therapy) and 36 neurotypical controls (29 males; mean age 10.2 years; controls were not assessed for GI disease) were tested for MPO plasma concentration using Enzyme Linked Immunosorbent Assays (ELISAs). Plasma concentration of MPO in autistic individuals was compared to plasma concentration of copper and zinc. RESULTS: We found that individuals with autism, receiving no therapy, did not have significantly lower plasma MPO levels when compared to controls. In the autistic group, MPO levels were significantly lower in individuals taking probiotic therapy. In addition, plasma copper levels were significantly lower in autistic individuals taking probiotics compared to those not taking probiotics, but plasma zinc levels were not different in the probiotic group. DISCUSSION: These results suggest a relationship between low MPO levels found in a group of autistic individuals and probiotic therapy. By possibly changing gut bacterial flora and thereby changing absorption properties in the gut, probiotic therapy was also associated with lower copper levels.

Increased Epidermal Growth Factor Receptor (EGFR) Associated with Hepatocyte Growth Factor (HGF) and Symptom Severity in Children with Autism Spectrum Disorders (ASDs).

BACKGROUND: One in 88 children in the US is thought to have one of the autism spectrum disorders (ASDs). ASDs are characterized by social impairments and communication problems. Growth factors and their receptors may play a role in the etiology of ASDs. Research has shown that epidermal growth factor receptor (EGFR) activation is associated with nerve cell development and repair. This study was designed to measure plasma levels of EGFR in autistic children and correlate these levels with its ligand, epidermal growth factor, other related putative biomarkers such as hepatocyte growth factor (HGF), the ligand for MET (MNNG HOS transforming gene) receptor, as well as the symptom severity of 19 different behavioral symptoms. SUBJECTS AND METHODS: Plasma EGFR concentration was measured in 33 autistic children and 34 age- and gender-similar neurotypical controls, using an enzyme-linked immunosorbent assay. Plasma EGFR levels were compared to putative biomarkers known to be associated with EGFR and MET and severity levels of 19 autism-related symptoms. RESULTS: We found plasma EGFR levels significantly higher in autistic children, when compared to neurotypical controls. EGFR levels correlated with HGF and high-mobility group protein B1 (HMGB1) levels, but not other tested putative biomarkers, and EGFR levels correlated significantly with severity of expressive language, conversational language, focus/attention, hyperactivity, eye contact, and sound sensitivity deficiencies. CONCLUSIONS: These results suggest a relationship between increased plasma EGFR levels and designated symptom severity in autistic children. A strong correlation between plasma EGFR and HGF and HMGB1 suggests that increased EGFR levels may be associated with the HGF/Met signaling pathway, as well as inflammation.

Development, Implementation and Use of Electronic Surveillance for Ventilator-Associated Events (VAE) in Adults.

Mechanical ventilation provides an important, life-saving therapy for severely ill patients, but ventilated patients are at an increased risk for complications, poor outcomes, and death during hospitalization.1 The timely measurement of negative outcomes is important in order to identify potential issues and to minimize the risk to patients. The Centers for Disease Control and Prevention (CDC) created an algorithm for identifying Ventilator-Associated Events (VAE) in adult patients for reporting to the National Healthcare Safety Network (NHSN). Currently, the primarily manual surveillance tools require a significant amount of time from hospital infection prevention (IP) staff to apply and interpret. This paper describes the implementation of an electronic VAE tool using an internal clinical data repository and an internally developed electronic surveillance system that resulted in a reduction of labor efforts involved in identifying VAE at Barnes Jewish Hospital (BJH).

Decreased Hepatocyte Growth Factor (HGF) and Gamma Aminobutyric Acid (GABA) in Individuals with Obsessive-Compulsive Disorder (OCD).

INTRODUCTION: There is support for the role of gamma aminobutyric acid (GABA) in the etiology of mood disorders. Recent research has shown that hepatocyte growth factor (HGF) modulates GABAergic inhibition and seizure susceptibility. This study was designed to determine and correlate plasma levels of HGF and GABA as well as symptom severity in individuals with obsessive-compulsive disorder (OCD). SUBJECTS AND METHODS: Plasma from 15 individuals with OCD (9 males, 6 females;, mean age 38.7 years) and 17 neurotypical controls (10 males, 7 females; mean age 35.2 years) was assessed for HGF, GABA, urokinase plasminogen activator (uPA), and urokinase plasminogen activator receptor (uPAR) concentration using enzyme-linked immunosorbest assays ELISAs. Symptom severity was assessed in these OCD individuals and compared with HGF and GABA concentrations. RESULTS: In this preliminary study, individuals with OCD had significantly decreased HGF levels, decreased plasma levels of GABA and decreased uPA. We found that both uPA and uPAR levels correlate with HGF. Both low uPA and low uPAR levels correlate with high symptom severity in individuals with OCD. Low GABA levels in OCD individuals also correlate with high symptom severity. DISCUSSION: These results demonstrate a preliminary association between HGF, GABA, uPA levels, and OCD and suggest that plasma GABA and uPA levels are related to symptom severity in individuals with OCD.

Correlation Between Hepatocyte Growth Factor (HGF) and Gamma-Aminobutyric Acid (GABA) Plasma Levels in Autistic Children.

There is much support for the role of Gamma-Aminobutyric acid (GABA) in the etiology of autism. Recent research has shown that hepatocyte growth factor (HGF) modulates GABAergic inhibition and seizure susceptibility. This study was designed to determine and correlate plasma levels of HGF, GABA, as well as symptom severity, in autistic children and neurotypical controls. Plasma from 48 autistic children and 29 neurotypical controls was assessed for HGF and GABA concentration using ELISAs. Symptom severity was assessed in these autistic individuals and compared to HGF and GABA concentrations. We previously reported that autistic children had significantly decreased levels of HGF. In this study, the same autistic children had significantly increased plasma levels of GABA (P = 0.002) and decreased HGF levels correlated with these increased GABA levels (r = 0.3; P = 0.05). High GABA levels correlated with increasing hyperactivity (r = 0.6; P = 0.0007) and impulsivity severity (r = 0.5; P = 0.007), tip toeing severity (r = 0.35; P = 0.03), light sensitivity (r = 0.4; P = 0.02), and tactile sensitivity (r = 0.4; P = 0.01). HGF levels did not correlate significantly with any symptom severity. These results suggest an association between HGF and GABA levels and suggest that plasma GABA levels are related to symptom severity in autistic children.

Discontinuation of reflex testing of stool samples for vancomycin-resistant enterococci resulted in increased prevalence.

Discontinuation of reflex testing of stool submitted for Clostridium difficile testing for vancomycin-resistant enterococci (VRE) led to an increase in the number of patients with healthcare-associated VRE bacteremia and bacteriuria (0.21 vs 0.36 cases per 1,000 patient-days; P<.01). Cost-benefit analysis showed reflex screening and isolation of VRE reduced hospital costs.

Decreased Epidermal Growth Factor (EGF) Associated with HMGB1 and Increased Hyperactivity in Children with Autism.

BACKGROUND: Autism spectrum disorders (ASDs), characterized by impaired social interactions and deficits in verbal and nonverbal communication, are thought to affect 1 in 88 children in the United States. There is much support for the role of growth factors in the etiology of autism. Recent research has shown that epithelial growth factor (EGF) is decreased in young autistic children (2-4 years of age). This study was designed to determine plasma levels of EGF in an older group of autistic children (mean age 10.6 years) and to correlate these EGF levels with putative biomarkers HGF, uPA, uPAR, GAD2, MPO GABA, and HMGB1, as well as symptom severity of 19 different symptoms. SUBJECTS AND METHODS: Plasma from 38 autistic children, 11 children with pervasive developmental disorder (PDD-NOS) and 40 neurotypical, age and gender similar controls was assessed for EGF concentration using ELISAs. Severity of 19 symptoms (awareness, expressive language, receptive language, (conversational) pragmatic language, focus/attention, hyperactivity, impulsivity, perseveration, fine motor skills, gross motor skills, hypotonia (low muscle tone), tiptoeing, rocking/pacing, stimming, obsessions/fixations, eye contact, sound sensitivity, light sensitivity, and tactile sensitivity) was assessed and then compared to EGF concentrations. RESULTS: In this study, we found EGF levels in autistic children and those with PDD-NOS to be significantly lower when compared with neurotypical controls. EGF levels correlated with HMGB1 levels but not the other tested putative biomarkers, and EGF correlated negatively with hyperactivity, gross motor skills, and tiptoeing but not other symptoms. CONCLUSIONS: These results suggest an association between decreased plasma EGF levels and selected symptom severity. We also found a strong correlation between plasma EGF and HMGB1, suggesting inflammation is associated with decreased EGF.

Patient- and device-specific risk factors for peripherally inserted central venous catheter-related bloodstream infections.

OBJECTIVE: To determine the patient- and device-specific risk factors for hospital-acquired peripherally inserted central venous catheter-related bloodstream infections (PICC BSIs) in adult patients. DESIGN: Nested case-control study. SETTING: Barnes-Jewish Hospital, a 1,252-bed tertiary care teaching hospital. PATIENTS: Adult patients with PICCs placed from January 1, 2006, through July 31, 2008. METHODS: PICC BSI cases were identified using the National Healthcare Safety Network definition. Uninfected control patients with PICCs in place were randomly selected at a 3∶1 ratio. Patient- and device-related variables were examined using multivariate analysis. RESULTS: The overall PICC BSI rate was 3.13 per 1,000 catheter-days. Independent risk factors for PICC BSIs included congestive heart failure (odds ratio [OR], 2.0 [95% confidence interval (CI), 1.26-3.17]; P = .003), intra-abdominal perforation (OR, 5.66 [95% CI, 1.76-18.19]; P = .004), Clostidium difficile infection (OR, 2.25 [95% CI, 1.17-4.33]; P = .02), recent chemotherapy (OR, 3.36 [95% CI, 1.15-9.78]; P = .03), presence of tracheostomy (OR, 5.88 [95% CI, 2.99-11.55]; P < .001), and type of catheter (OR for double lumen, 1.89 [95% CI, 1.15-3.10]; P = .01 ; OR for triple lumen, 2.87 [95% CI, 1.39-5.92]; P = .004). Underlying chronic obstructive pulmonary disease (OR, 0.48 [95% CI, 0.29-0.78]; P = .03) and admission to surgical (OR, 0.43 [95% CI, 0.24-0.79]; P = .006) or oncology and orthopedic (OR, 0.35 [95% CI, 0.13-0.99]; P = .05) services were less likely to be associated with having a PICC BSI. CONCLUSIONS: We identified several novel factors related to PICC BSIs. These factors may inform preventive measures.

Long-term effect of infection prevention practices and case mix on cesarean surgical site infections.

OBJECTIVE: To estimate trends in patient characteristics and obstetric complications in an 8-year cohort of patients undergoing cesarean delivery and to use time series analysis to estimate the effect of infection prevention interventions and secular trends in patient characteristics on postcesarean delivery surgical site infections. METHODS: A multivariable autoregressive integrated moving average model was used to perform time series analysis on a 96-month retrospective cohort of patients who underwent cesarean delivery (January 2003-December 2010) in a U.S. tertiary care hospital. RESULTS: We identified 8,668 women who underwent cesarean delivery. Median age was 26 years (range 12-53 years), 3,093 (35.7%) of patients had body mass indexes (BMIs) of 35 or greater, 2,561 (29.5%) were of white race, and 303 (3.5%) had a surgical site infection. Over the study period, there was a significant increase in the proportion of patients who underwent cesarean delivery who had BMIs of 35 or higher, hypertension or mild preeclampsia, and severe preeclampsia or eclampsia. A nonseasonal autoregressive integrated moving average model with a linear trend and no autocorrelation was identified. In the multivariable autoregressive integrated moving average model of postcesarean surgical site infections, implementation of a policy to administer prophylactic antibiotics within 1 hour before incision, instead of at the time of cord clamp, led to a 48% reduction in cesarean delivery surgical site infections (Δ=-5.4 surgical site infections per 100 cesarean deliveries; P<.001). CONCLUSION: A change in policy to administer prophylactic antibiotics before incision resulted in a significant reduction in postcesarean surgical site infections. LEVEL OF EVIDENCE: III.

Accuracy and complications associated with posterior C1 screw fixation techniques: a radiographic and clinical assessment.

BACKGROUND CONTEXT: The variable C1 anatomy can make instrumentation challenging and prone to potentially severe complications. New techniques have expanded available options. PURPOSE: The aims of this study were to evaluate a large series of posterior C1 screws to determine accuracy by computed tomography (CT) scan; assess dimensions of "safe bony windows" with CT; and assess perioperative complication rate related to errant screw placement. STUDY DESIGN: Retrospective review of a single tertiary care spine database to identify patients with C1 instrumentation between December 2002 and September 2008. PATIENT SAMPLE: The sample comprised 176 patients with 344 C1 screws. All 176 patients were assessed for perioperative complications related to their C1 screws. Twenty-nine patients did not have postoperative CT scans, leaving 147 patients with 286 screws for analysis of screw accuracy. OUTCOME MEASURES: The outcome measures consisted of a radiographic assessment of accuracy of placement of C1 instrumentation and a clinical assessment of perioperative complications related to C1 instrumentation focusing on neurologic and vascular injuries. METHODS: Clinical data were obtained from the medical record. Radiographic analyses included preoperative and postoperative CT scans to quantify the patients' bone and classify accuracy of instrumentation. Screws were graded using the following definitions: Type I, screw threads completely within the bone; Type II, less than half the diameter of the screw violates the surrounding cortex; and Type III, clear violation of transverse foramen or spinal canal. RESULTS: One hundred seventy-six patients (97 males and 79 females) underwent posterior C1 screw (lateral mass [LM] or transarticular [TA]) fixation. A total of 344 screws were placed with 216 LM screws and 128 TA screws. Twenty-nine patients (58 screws) did not have postoperative CT scans and were not included for analysis of radiographic accuracy but were included in assessment of complications based on medical records. Ninety-six percent of screws (Type I or II) were rated as "safe," and 86% of screws were rated as being ideal (Type I). Twelve screws (4%) were unacceptably placed (Type III). There were no known neurologic or vertebral artery injuries. One patient underwent revision surgery for a medially placed screw. Mean C1 LM width was 10.5 mm across all patients. Estimated blood loss averaged 331 mL. CONCLUSIONS: Our findings demonstrate a low incidence of complications associated with posterior screw instrumentation of the C1 LM.

A Clostridium difficile infection "intervention": change in toxin assay results in fewer C difficile infection cases without changes in patient outcomes.

BACKGROUND: Clostridium difficile infection (CDI) is most commonly diagnosed using toxin enzyme immunoassays (EIAs). A sudden decrease in CDI incidence was noted after a change in the EIA used at Barnes-Jewish Hospital in St Louis. The objective of this study was to determine whether the decreased CDI incidence related to the change in EIA resulted in adverse patient outcomes. METHODS: Electronic hospital databases were used to collect data on demographics, outcomes, and treatment of inpatients who had a C difficile toxin assay performed between January 4, 2009, and April 3, 2009 (period A, preassay change) and between May 21, 2009, and August 17, 2009 (period B, postassay change). RESULTS: Assays were positive in 240 of 1,221 patients (19.7%) during period A and in 106 of 1160 patients (9.1%) during period B (P < .01). There was no difference in mortality or discharge to hospice between the 2 periods (10.3% vs 10.1%; P = .90). Patients tested in period B were less likely to receive metronidazole or oral vancomycin (P < .01). CONCLUSIONS: The new EIA resulted in fewer positive tests and reduced anti-CDI therapy. There was no difference in mortality between the 2 periods, suggesting that the decreased incidence was due to increased assay specificity, not decreased sensitivity.

Plasma copper and zinc concentration in individuals with autism correlate with selected symptom severity.

AIM: To assess plasma zinc and copper concentration in individuals with autism and correlate these levels with symptom severity. SUBJECTS AND METHODS: Plasma from 102 autistic individuals, and 18 neurotypical controls, were tested for plasma zinc and copper using inductively-coupled plasma-mass spectrometry. Copper and zinc levels and Cu/Zn were analyzed for possible correlation with severity of 19 symptoms. RESULTS: Autistic individuals had elevated plasma levels of copper and Cu/Zn and lower, but not significantly lower, plasma Zn compared to neurotypical controls. There was a correlation between Cu/Zn and expressive language, receptive language, focus attention, hyperactivity, fine motor skills, gross motor skills and Tip Toeing. There was a negative correlation between plasma zinc concentration and hyperactivity, and fine motor skills severity. DISCUSSION: These results suggest an association between plasma Cu/Zn and severity of symptoms associated with autism.

Peripherally inserted central venous catheter-associated bloodstream infections in hospitalized adult patients.

BACKGROUND: Limited data on the risk of peripherally inserted central venous catheter-associated bloodstream infections (PICC BSIs) in hospitalized patients are available. In 2007, dedicated intravenous therapy nurses were no longer available to place difficult peripheral intravenous catheters or provide PICC care Barnes-Jewish Hospital. OBJECTIVES: To determine the hospital-wide incidence of PICC BSIs and to assess the effect of discontinuing intravenous therapy service on PICC use and PICC BSI rates. SETTING: A 1,252-bed tertiary care teaching hospital. METHODS: A 31-month retrospective cohort study was performed. PICC BSIs were defined using National Healthcare Safety Network criteria. RESULTS: In total, 163 PICC BSIs were identified (3.13 BSIs per 1,000 catheter-days). PICC use was higher in intensive care units (ICUs) than non-ICU areas (PICC utilization ratio, 0.109 vs 0.059 catheter-days per patient-day for ICU vs non-ICU; rate ratio [RR], 1.84 [95% confidence interval {CI}, 1.78-1.91]). PICC BSI rates were higher in ICUs (4.79 vs 2.79 episodes per 1,000 catheter-days; RR, 1.7 [95% CI, 1.10-2.61]). PICC use increased hospital-wide after the intravenous therapy service was discontinued (0.049 vs 0.097 catheter-days per patient-day; P =.01), but PICC BSI rates did not change (2.68 vs 3.63 episodes per 1,000 catheter-days; P =.06). Of PICC BSIs, 73% occurred in non-ICU patients. CONCLUSIONS: PICC use and PICC BSI rates were higher in ICUs; however, most of the PICC BSIs occurred in non-ICU areas. Reduction in intravenous therapy services was associated with increased PICC use across the hospital, but PICC BSI rates did not increase.

Posterior C2 instrumentation: accuracy and complications associated with four techniques.

STUDY DESIGN: Retrospective review of a single tertiary care spine database to identify patients with C2 instrumentation between January 2001 and September 2008. OBJECTIVE: (1) Evaluate a large series of posterior C2 screws to determine accuracy by computed tomography (CT) scan, (2) assess dimensions of "safe bony windows" with CT, and (3) assess perioperative complication rate related to errant screw placement. SUMMARY OF BACKGROUND DATA: The variable C2 anatomy can make instrumentation challenging and prone to potentially severe complications. New techniques have expanded available options. METHODS: Clinical data were obtained from the medical record. Radiographic analyses included preoperative and postoperative CT scans to quantify the patients' bone and to classify accuracy of instrumentation. Screws were graded using the following definitions: RESULTS: Seven hundred and thirty-six screws in 383 patients were identified. Fifty-five patients were excluded because of lack of data leaving 328 patients (188 male patients, 140 female patients) with 633 screws. Three hundred and thirty-nine pedicle, 154 transarticular, 63 laminar, and 77 short pars screws were placed, and of the 509 screws with postoperative CT scans, accuracy rates (Types I and II) were 98.8%, 98.5%, 100%, and 94.6%, respectively. Eight were unacceptably placed: two medially and six encroaching on the vertebral artery foramen. One patient had a vertebral artery occlusion and another had a dissection. There were no neurologic injuries. Mean CT measurements of pedicle height, axial width, and laminar width were 8.1, 5.8, and 5.7 mm respectively, with males having significantly larger pedicle height (P<0.001), pedicle width (P<0.001), and laminar width (P<0.022). CONCLUSION: We show a lower than previously reported incidence of complications associated with posterior C2 screw placement. The multiple techniques of posterior C2 fixation available allow for flexibility in determining ideal technique.

Increased Copper in Individuals with Autism Normalizes Post Zinc Therapy More Efficiently in Individuals with Concurrent GI Disease.

AIM: To assess plasma zinc and copper concentration in individuals with autism. SUBJECTS AND METHODS: Plasma from 79 autistic individuals, and 18 age and gender similar neurotypical controls, were tested for plasma zinc and copper using inductively-coupled plasma-mass spectrometry. RESULTS: Autistic individuals had significantly elevated plasma levels of copper and Cu/Zn and lower, but not significantly lower, plasma Zn compared to neurotypical controls. Zn levels increased significantly in autistic individuals with and without GI disease after zinc therapy. Cu decreased significantly after zinc therapy in the GI disease group but not in the autistic group without GI disease. Autistic children significantly improved with respect to hyperactivity and stimming after zinc therapy in autistic children with GI disease. Autistic children without GI disease did not improve in these symptoms after the same therapy. DISCUSSION: These results suggest an association between zinc and copper plasma levels and autism, and they suggest that zinc therapy may be most effective at lowering copper levels in autistic children with GI disease.