Proteolipid Protein-Induced Mouse Model of Multiple Sclerosis Requires B Cell-Mediated Antigen Presentation.

The pathogenic role B cells play in multiple sclerosis is underscored by the success of B cell depletion therapies. Yet, it remains unclear how B cells contribute to disease, although it is increasingly accepted that mechanisms beyond Ab production are involved. Better understanding of pathogenic interactions between B cells and autoreactive CD4 T cells will be critical for novel therapeutics. To focus the investigation on B cell:CD4 T cell interactions in vivo and in vitro, we previously developed a B cell-dependent, Ab-independent experimental autoimmune encephalomyelitis (EAE) mouse model driven by a peptide encompassing the extracellular domains of myelin proteolipid protein (PLPECD). In this study, we demonstrate that B cell depletion significantly inhibited PLPECD-induced EAE disease, blunted PLPECD-elicited delayed-type hypersensitivity reactions in vivo, and reduced CD4 T cell activation, proliferation, and proinflammatory cytokine production. Further, PLPECD-reactive CD4 T cells sourced from B cell-depleted donor mice failed to transfer EAE to naive recipients. Importantly, we identified B cell-mediated Ag presentation as the critical mechanism explaining B cell dependence in PLPECD-induced EAE, where bone marrow chimeric mice harboring a B cell-restricted MHC class II deficiency failed to develop EAE. B cells were ultimately observed to restimulate significantly higher Ag-specific proliferation from PLP178-191-reactive CD4 T cells compared with dendritic cells when provided PLPECD peptide in head-to-head cultures. We therefore conclude that PLPECD-induced EAE features a required pathogenic B cell-mediated Ag presentation function, providing for investigable B cell:CD4 T cell interactions in the context of autoimmune demyelinating disease.

Obesity, insulin resistance, adiponectin, and PPAR-γ gene expression in broiler chicks fed diets supplemented with fat and green tea (Camellia sinensis) extract.

Adipose tissue is an active endocrine organ secreting several adipokines, especially adiponectin, that play an important role in regulating insulin function in the body of mammals. Therefore, this study was aimed to investigate the association between abdominal fat deposit, insulin resistance, peroxisome proliferator-activated receptor gamma (PPAR-γ), and adiponectin gene (AG) expression in broiler chicks fed diets high in unsaturated fat supplemented with green tea extract (GTE). A total of 300 one-day-old female Ross 308 broiler chicks were allocated to 6 dietary treatments in a completely randomized design with a factorial arrangement of two levels of GTE (0 and 500 mg/kg diet) × three levels of fat inclusion [without fat (control group), soybean oil (SO), and tallow (Ta)]. Each treatment was replicated five times. At the end of the experiment (day 49), two chicks from each replicate weighing an average of pen weight were bled and then slaughtered for further analysis. Abdominal fat percentage, fasting concentration of blood glucose, triglyceride and insulin, glycogen reserves of breast and liver tissues, and PPAR-γ and AG expression were determined. The insulin resistance index of the Quantitative Insulin Sensitivity Check Index (QUICKI) was calculated using the fasting plasma glucose and insulin concentrations. The highest abdominal fat percentage and the lowest carcass yield were obtained in chicks fed SO-supplemented diet (P < 0.05). Chicks fed diet supplemented with SO showed the highest PPAR-γ gene expression (P < 0.05). SO-rich diets suppressed AG expression in chickens' abdominal fat tissue, and the birds fed with SO-supplemented diet showed a significant decrease in AG expression compared with the control (P < 0.05). Chicks fed diet supplemented with SO showed lower QUICKI and breast glycogen reserve compared with the control group (P < 0.05). A significant increase in blood glucose and triglyceride concentrations was observed in birds fed SO-supplemented diets (P < 0.05). AG and PPAR-γ expression increased and decreased by GTE, respectively. QUICKI tended (P = 0.09) to be greater in GTE-supplemented chicks; however, the effect of GTE supplementation on carcass yield, abdominal fat percentage, and blood insulin and glucose concentration was not significant. The findings of this study showed that SO-rich diets via increased PPAR-γ gene expression and decreased AG expression in abdominal fat may lead to insulin resistance in female broiler chicks.

Development and Validation of a Prediction Model for Pain and Functional Outcomes After Lumbar Spine Surgery.

Importance: Functional impairment and pain are common indications for the initiation of lumbar spine surgery, but information about expected improvement in these patient-reported outcome (PRO) domains is not readily available to most patients and clinicians considering this type of surgery. Objective: To assess population-level PRO response after lumbar spine surgery, and develop/validate a prediction tool for PRO improvement. Design, Setting, and Participants: This statewide multicenter cohort was based at 15 Washington state hospitals representing approximately 75% of the state's spine fusion procedures. The Spine Surgical Care and Outcomes Assessment Program and the survey center at the Comparative Effectiveness Translational Network prospectively collected clinical and PRO data from adult candidates for lumbar surgery, preoperatively and postoperatively, between 2012 and 2016. Prediction models were derived for PRO improvement 1 year after lumbar fusion surgeries on a random sample of 85% of the data and were validated in the remaining 15%. Surgical candidates from 2012 through 2015 were included; follow-up surveying continued until December 31, 2016, and data analysis was completed from July 2016 to April 2017. Main Outcomes and Measures: Functional improvement, defined as a reduction in Oswestry Disability Index score of 15 points or more; and back pain and leg pain improvement, defined a reduction in Numeric Rating Scale score of 2 points or more. Results: A total of 1965 adult lumbar surgical candidates (mean [SD] age, 61.3 [12.5] years; 944 [59.6%] female) completed baseline surveys before surgery and at least 1 postoperative follow-up survey within 3 years. Of these, 1583 (80.6%) underwent elective lumbar fusion procedures; 1223 (77.3%) had stenosis, and 1033 (65.3%) had spondylolisthesis. Twelve-month follow-up participation rates for each outcome were between 66% and 70%. Improvements were reported in function, back pain, and leg pain at 12 months by 306 of 528 surgical patients (58.0%), 616 of 899 patients (68.5%), and 355 of 464 patients (76.5%), respectively, whose baseline scores indicated moderate to severe symptoms. Among nonoperative patients, 35 (43.8%), 47 (53.4%), and 53 (63.9%) reported improvements in function, back pain, and leg pain, respectively. Demographic and clinical characteristics included in the final prediction models were age, sex, race, insurance status, American Society of Anesthesiologists score, smoking status, diagnoses, prior surgery, prescription opioid use, asthma, and baseline PRO scores. The models had good predictive performance in the validation cohort (concordance statistic, 0.66-0.79) and were incorporated into a patient-facing, web-based interactive tool (https://becertain.shinyapps.io/lumbar_fusion_calculator). Conclusions and Relevance: The PRO response prediction tool, informed by population-level data, explained most of the variability in pain reduction and functional improvement after surgery. Giving patients accurate information about their likelihood of outcomes may be a helpful component in surgery decision making.

A sinusoidal function and the Nelder-Mead simplex algorithm applied to growth data from broiler chickens.

There has been much recent interest in mathematical developments for the analysis of growth in poultry. In this paper, we present a sinusoidal function to describe the evolution of growth as a function of time based on real life experiments. The function was evaluated with regard to its ability to describe the relationship between body weight and age in broilers and was compared to 4 standard growth functions: Gompertz, logistic, Lopez, and Richards. In order to estimate the model parameters, we adopted a global optimization method based on a direct search method instead of using gradient-based techniques. The results of this study show that both the sinusoidal function and the direct search method precisely describe the growth dynamics of broiler chickens. Fitting the growth functions to different data profiles nearly always led to the same or less maximized log-likelihood values for the sinusoidal equation, which is an indication of its superiority in describing growth data from broiler chickens.

Mesoscale Simulation and Machine Learning of Asphaltene Aggregation Phase Behavior and Molecular Assembly Landscapes.

Asphaltenes constitute the heaviest fraction of the aromatic group in crude oil. Aggregation and precipitation of asphaltenes during petroleum processing costs the petroleum industry billions of dollars each year due to downtime and production inefficiencies. Asphaltene aggregation proceeds via a hierarchical self-assembly process that is well-described by the Yen-Mullins model. Nevertheless, the microscopic details of the emergent cluster morphologies and their relative stability under different processing conditions remain poorly understood. We perform coarse-grained molecular dynamics simulations of a prototypical asphaltene molecule to establish a phase diagram mapping the self-assembled morphologies as a function of temperature, pressure, and n-heptane:toluene solvent ratio informing how to control asphaltene aggregation by regulating external processing conditions. We then combine our simulations with graph matching and nonlinear manifold learning to determine low-dimensional free energy surfaces governing asphaltene self-assembly. In doing so, we introduce a variant of diffusion maps designed to handle data sets with large local density variations, and report the first application of many-body diffusion maps to molecular self-assembly to recover a pseudo-1D free energy landscape. Increasing pressure only weakly affects the landscape, serving only to destabilize the largest aggregates. Increasing temperature and toluene solvent fraction stabilizes small cluster sizes and loose bonding arrangements. Although the underlying molecular mechanisms differ, the strikingly similar effect of these variables on the free energy landscape suggests that toluene acts upon asphaltene self-assembly as an effective temperature.

Effect of Calcium Hydroxide Based Intracanal Medicaments on the Apical Sealing Ability of Resin Based Sealer and Guttapercha Obturated Root Canals.

INTRODUCTION: Calcium Hydroxide (CH) is one of the most commonly used intracanal medicaments which can be used with various vehicles. AIM: The aim of this in vitro study was to evaluate the effect of three CH based intracanal medicaments on the apical sealing ability of AH Plus - guttapercha obturation. MATERIALS AND METHODS: Crowns of 100 extracted single rooted human teeth were sectioned at the Cemento-Enamel Junction (CEJ) to a standardized length. The root canals were instrumented upto ISO size 40 using step back technique and the specimens were randomly divided into two control and four experimental groups. The control groups were not medicated. Specimens in positive control group (Group I) were obturated with guttapercha without placing sealer and in negative control group (Group II) were obturated with guttapercha and AH Plus sealer. Among the experimental groups, specimens of Group III were not medicated while groups IV, V and VI were medicated with CH-saline, CH-2% Chlorhexidine (CHX) and Vitapex respectively for a period of 14 days. The medicaments were removed from the specimens and the teeth were obturated with AH Plus sealer and guttapercha using lateral compaction technique. The specimens were immersed in India ink dye, demineralized and diphanized. The extent of dye penetration was assessed using a 10X stereomicroscope. Data obtained was statistically analyzed by one-way ANOVA (p<0.05) followed by Post-hoc Tukey test. RESULTS: Amongst the three CH medicaments, CH-2% CHX when used as an intracanal medicament showed a significantly higher microleakage as compared to the other groups with p<0.001. The microleakage values between the remaining groups were not statistically significant. CONCLUSION: Under the conditions of this study it was concluded that all groups with or without intracanal medicament showed apical leakage. The vehicle used to carry CH may significantly influence the apical sealing ability of guttapercha - AH Plus obturated canals.

Cellular Events and Pathophysiology of SCI.

Spinal cord injury (SCI) has occurred in 2.5 million people worldwide, and 130,000 new cases are reported each year. SCI most commonly consists of a compression injury with hemorrhage into gray matter and loss of neurons, oligodendroglia, and astrocytes, followed by invasion of lymphocytes and macrophages; cavitation of the cord follows, then Wallerian degeneration of ascending and descending tracts and loss of neuronal circuitry, culminating in glial scar perpendicular to the direction of the axon. Onset of necrosis occurs within 24 hours. Spontaneous repair is incomplete and involves limited sprouting of axons and new spinal circuits that bypass the lesion and move into descending tracts, resulting in indirect connections with lumbar motor neurons.

Periorbital trauma from pit bull terrier attacks.

PURPOSE: To report the nature of periorbital trauma after pit bull attacks. While these attacks have been well-characterized in the popular media, no case series has documented the ophthalmic manifestations of this trauma. METHODS: We retrospectively reviewed all cases of pit bull terrier attacks that presented to the oculoplastic and orbital surgery service at Albany Medical Center between 2008 and 2011. The age, gender, extent of the injuries, care provided, follow up interval, and complication rate were evaluated for each patient. RESULTS: Seven patients were identified, with a mean age of 17.2 years. Six of the seven patients were in the pediatric age group. All patients suffered eyelid lacerations, and only one patient had additional injuries. Four patients (57.2%) suffered a canalicular laceration. Despite the lack of post-operative oral antibiotic use, no patient developed a wound infection. CONCLUSIONS: In the ophthalmic setting, pit bull terrier attacks most frequently involve children and result in eyelid lacerations. Canalicular injuries are common after these attacks.

Orbital cellulitis with subperiosteal abscess: demographics and management outcomes.

PURPOSE: Infectious orbital cellulitis represents a serious threat to vision and, if untreated, poses significant morbidity risk. In this study, the authors attempt to further characterize the features of orbital cellulitis with subperiosteal abscess (SPA) and determine outcomes based on the type of surgical intervention employed. METHODS: Data were obtained by retrospective chart review of all inpatient admissions for orbital inflammation/cellulitis from Sept 2005 to April 2010. Charts were reviewed for demographic information, radiographic and clinic evidence of orbital cellulitis, presence of SPA (defined by radiographic criteria), interventions taken (surgical and nonsurgical), presence of concurrent sinusitis, types of microbes present, and duration of hospital admission. Statistical analysis was performed using chi-square tests. RESULTS: A total of 97 patients were admitted with a diagnosis of orbital inflammation/cellulitis, of whom 49 patients had clinical and/or radiographic evidence of orbital cellulitis. Twenty-four patients had radiographic evidence of SPA. All patients with SPA had concurrent sinusitis, and 16 patients underwent initial surgical intervention. Nine patients had external transcaruncular/transcutaneous SPA drainage only, 6 had combined SPA and sinus drainage, and one had sinus drainage alone. Of those that underwent SPA-only drainage, 5 had SPA reaccumulation, while no reaccumulation occurred with combined SPA and sinus drainage. No reaccumulation occurred if the SPA was less than 2 cm in its greatest diameter. CONCLUSION: In this study, for those abscesses larger than 2 cm, combined sinus and SPA drainage was associated with improved treatment outcome, demonstrated by absence of abscess reaccumulation and shorter hospital stay. SPA-only drainage was more frequently associated with SPA reaccumulation.

Primary orbital manifestation of Hodgkin lymphoma in a 3-year-old child.

Hodgkin lymphoma is exceedingly rare in children, as is primary orbital manifestation of systemic Hodgkin lymphoma in any age category. The authors describe the clinicopathologic manifestations of a rare case of systemic Hodgkin lymphoma with primary orbital manifestation in a 3-year-old boy with histologically proven Hodgkin lymphoma with mixed cellularity. After an incisional biopsy and tumor debulking, followed by systemic workup, the diagnosis of stage IVA Hodgkin lymphoma was made. He underwent treatment with 4 cycles of adriamycin, bleomycin, vincristine, etopiside, prednisone, and cyclophosphamide, followed by involved field radiation. He has been followed at regular intervals for 6 years. Scans have shown resolution at all sites, and blood counts have remained normal. To the best of the authors' knowledge, this is the youngest patient with primary orbital manifestation of Hodgkin lymphoma reported in the English literature.

Warfarin dosing in patients with impaired kidney function.

BACKGROUND: In patients with kidney impairment, warfarin, a drug metabolized primarily by the cytochrome P-450 system, is initiated at similar doses and managed similarly as in the general medical population. Unfortunately, few data exist to guide dose adjustment in patients with decreased kidney function. Here, we determine the degree of warfarin dose reduction associated with kidney impairment and make recommendations for warfarin dosing. STUDY DESIGN: Cross-sectional analysis. SETTING & PARTICIPANTS: Long-term warfarin users followed up at anticoagulation clinics (n = 980); 708 participants from the University of Alabama (UAB) and 272 participants from the University of Chicago (UIC). PREDICTOR: No/mild (estimated glomerular filtration rate [eGFR] ≥ 60 mL/min/1.73 m(2)), moderate (eGFR, 30-59 mL/min/1.73 m(2)), and severe (eGFR < 30 mL/min/1.73 m(2)) kidney impairment; CYP2C9 and VKORC1 genotype; age; race; sex; body mass; sociodemographic factors; smoking status; alcohol; vitamin K intake; comorbid conditions (eg, congestive heart failure); and drug interactions (eg, amiodarone and statins). OUTCOME & MEASUREMENT: Warfarin dose (milligrams per day) was evaluated using linear regression after adjustment for clinical, demographic, and genetic factors. RESULTS: Prevalences of moderate (31.8% and 27.6%) and severe kidney impairment (8.9% and 6.6%) were similar in the UAB and UIC cohorts. Warfarin dose requirements were significantly lower in patients with moderate and severe kidney impairment compared with those with no/mild kidney impairment in the UAB (P < 0.001) and UIC (P < 0.001) cohorts. Compared with patients with no/mild kidney impairment, patients with moderate kidney impairment required 9.5% lower doses (P < 0.001) and patients with severe kidney impairment required 19% lower doses (P < 0.001). LIMITATIONS: No measurement of warfarin, serum albumin, vitamin K, and coagulation factors; no evaluation of other markers (eg, cystatin). CONCLUSION: Moderate and severe kidney impairment were associated with a reduction in warfarin dose requirements.

Fellowship selection criteria in ophthalmic plastic and reconstructive surgery.

INTRODUCTION: Competition for subspecialty fellowship positions in ophthalmology continues to grow, and there is increasing interest regarding the factors considered important in fellowship selection. While a previous report evaluated the characteristics and criteria used by ophthalmology subspecialty program directors to select fellows in retina, cornea/external disease, and glaucoma fellowship programs, to the authors' knowledge no such study has evaluated Ophthalmic Plastic and Reconstructive Surgery (OPRS) fellowships. METHODS: The authors surveyed the program directors of all American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS)-sponsored fellowships in the United States and Canada. The survey contained 16 criteria related to the selection of fellows. A Likert scale ranging from 1 (not important) to 9 (very important) was used for prioritizing the criteria. Opportunity was afforded for comment on other measures, and program directors were also asked to select their most important factor used for fellow selection. RESULTS: The return rate of the completed surveys was 35 of 48 (73%). The 3 criteria with the highest mean Likert scale scores were the interview process (8.7), the ability to work and communicate with others (8.5), and letters of recommendation from subspecialty faculty (7.8). Likewise, the criterion selected as the single most important by respondents was the interview (58%), the ability to work and communicate with others (15%), and letters of recommendation from subspecialty faculty (15%). CONCLUSIONS: The authors' findings demonstrate that OPRS program directors place greater emphasis on qualities assessed during the interview, letters of recommendation from same specialty faculty, and the ability of the applicant to work and communicate with others. While not identical, our findings were similar to those noted for other ophthalmology subspecialties. The results support the suggestion that residents interested in fellowship training may benefit from faculty mentors in their area of interest early in their training. With the high interest in OPRS and other ophthalmology subspecialty fellowship training, the authors hope that this report will be useful to applicants, residency programs, and fellowship directors.

Ophthalmic plastic and reconstructive surgery (OPRS) fellowships: assessment and comparative data from the 2009 Specialties Matching Service.

INTRODUCTION: Among specialty fellowships available in the United States, matching in ophthalmic plastic and reconstructive surgery (OPRS) is widely thought of as an exceptionally competitive process. There are articles discussing fellowship selection and competition in other fields of medicine; however, little information is available in the peer review literature regarding the process for OPRS. METHODS: In this study, the authors evaluate match statistics, available from the National Resident Matching Program, for the class of fellows with appointments for training beginning in 2009. These statistics are compared with the 36 other advanced specialty training programs, in a wide range of medical and surgical fields, also participating in the Specialties Matching Service. RESULTS: OPRS fellowships are 1 of only 5 specialties that filled all available positions in the 2009 match and 1 of only 3 programs to fill all available positions in each of the past 4 years. In addition, 88.9% of positions were filled by U.S. graduates, the highest among all programs (range = 5.0%-88.9%, mean = 54.8%). Of those applicants who matched, OPRS fellowships had the lowest percentage of applicants, 22.9%, match at their first choice program among single specialty matches (range = 22.9%-75.0%). A total of 48.6% of OPRS applicants did not match-the highest among single specialty matches and the second highest among all programs, including combined specialty matches (range = 4.3%-53.5%). CONCLUSIONS: OPRS fellowships are among the most selective advanced specialty positions available in the United States. Among all specialty programs participating in the Specialties Matching Service, OPRS fellowships have nearly the highest unmatched applicant rate, highest U.S. graduate fill rate, and lowest first-choice match rate. These statistics indicate that the applicant pool is competitive and that both applicants and program directors (preceptors) are selective with their rankings. The authors believe these findings will be of interest to residents interested in further training in OPRS and to program directors, chairs, and others involved in the specialist educational process.

Comparison of pain scores with 30-gauge and 32-gauge needles for periocular botulinum toxin type a injections.

PURPOSE: To determine whether a 32-gauge needle can reduce the pain associated with periocular injections of botulinum toxin type A compared with 30-gauge needles. METHODS: In this prospective, randomized, masked study, 30 patients received bilateral periocular injections of botulinum toxin type A for benign essential blepharospasm. For each patient, a 30-gauge needle was used on one side of the face, and a 32-gauge needle was used on the other side. Equal number of injections and equal amounts of botulinum toxin type A at each injection site were administered on each side of the face. Patients were then asked to rate their pain level on each side of the face, using a standardized 11-point visual analogue pain scale. RESULTS: The average pain score was 4.38 +/- 2.02 for 30-gauge needles and 3.98 +/- 1.65 for 32-gauge needles. Statistical analysis via Mann-Whitney U test confirmed the null hypothesis that no statistical difference in pain level existed between the 2 needle sizes. CONCLUSIONS: There is no difference in perceived pain when comparing periocular botulinum toxin type A injections with 30- and 32-gauge needles. In addition, smaller gauge needles require special order and result in greater cost. The authors recommend continued use of 30-gauge needles for botulinum toxin injection in the office setting.

Incidence of ocular injury in visually asymptomatic orbital fractures.

PURPOSE: To determine the incidence of severe ocular injury in visually asymptomatic patients with orbital fractures. METHODS: Retrospective review of 241 cases of orbital fracture, of which 126 cases had ophthalmic evaluation within 1 week of injury and were included in our analysis. Fracture type, associated symptoms, and injuries were evaluated. Injuries were categorized into severe (requiring immediate evaluation), moderate (requiring evaluation within the next several days), and mild (may not require evaluation). The presence of symptoms and associated visual acuity and severity of injury were analyzed for statistical significance. RESULTS: Forty-six of 126 patients with orbital fractures were visually asymptomatic. Of these patients, none had severe injuries, 15 had moderate injuries, 23 had mild injuries, and 8 had no injuries. Of those with symptoms, 15 had severe injuries, 27 had moderate injuries, 35 had mild injuries, and 3 had no injuries. Using Fisher exact test analysis, asymptomatic patients were unlikely to have severe ocular injury in the setting of orbital fracture (p = 0.0009). In addition, visual acuity did not accurately predict the presence of severe ocular injury. CONCLUSION: Visually asymptomatic patients with orbital fractures do not have ocular injury requiring emergent evaluation.

Inferior vena cava thrombosis causing acute cauda equina syndrome. Case report.

The authors report a case of a 16-year-old girl who presented with a 1-week history of progressive low-back pain, buttock paresthesias, and bilateral lower extremity pain and weakness. Magnetic resonance (MR) imaging and MR venography studies of her lumbar spine revealed engorgement of the epidural venous plexus and mild compression of the cauda equina. A lower extremity and pelvic venogram revealed occlusive thrombosis of the femoral and iliac veins as well as of the inferior vena cava (IVC). The patient required an IVC thrombectomy due to progressive symptoms, after which she improved and returned to baseline status in 1 week. Imaging studies afterwards showed resolution of the venous engorgement and decompression of the cauda equina. This is the second published report of an association between IVC thrombosis and cauda equina syndrome.

Charcot arthropathy in relation to autonomic dysreflexia in spinal cord injury: case report and review of the literature.

Charcot spinal arthropathy has been described as a late complication of spinal cord injury. In patients with these injuries in whom the spine below the level of injury is insensate, joint trauma can progress until spinal instability ensues. The authors describe the case of a 50-year-old man with complete C-8 tetraplegia who experienced a 4-month history of episodic severe headaches, profuse sweating over his face and arms, and episodic severe hypertension in addition to a "grinding" sensation in the lower back. Charcot arthropathy at the T11-12 levels with pathological mobility was demonstrated on neuroimaging. Intraoperatively, a complete spinal cord transection was identified. Anterior and posterior thoracolumbar fusion across the mobile segment resulted in complete amelioration of signs and symptoms of autonomic dysreflexia. This entity, a common condition in the setting of spinal cord injury, has many triggers. Definitive treatment is targeted at the removal of the underlying cause. As demonstrated here, Charcot spinal arthropathy can act as a powerful trigger for induction of autonomic dysreflexia. Treatment of the associated spinal instability resulted in eradication of all signs and symptoms of the dysreflexia.