Contemporary trends in the epidemiology of traumatic spinal cord injury: changes in age and etiology.

BACKGROUND: Epidemiological features of spinal cord injury (SCI) have been changing over the last decades. We evaluated the contemporary trends in the epidemiology of traumatic SCI patients from a rehabilitation center. METHODS: In a cross-sectional study, a consecutive series of 348 patients with traumatic SCI were evaluated. Variables were collected through an epidemiological form, which included gender, age at injury, duration and cause of SCI. We investigated SCI epidemiological trends over time including the association between gender and age at injury with SCI features such as etiology, injury severity and level. RESULTS: The mean age at SCI has increased from 26.0 ± 11.8 in patients with SCI before 2003 to 37.9 ± 15.7 in those with SCI after 2009 (p < 0.001). Gunshot wounds were the main cause of injury in patients with SCI before 2003, dropping from 40.6 to 16.9% after 2009 and being surpassed by road traffic injuries (38.6%) and falls (31.4%) after 2009 (p < 0.001). Gender, SCI severity and level have not changed significantly over the time. CONCLUSIONS: There was a major increase in the average age of patients as well as changes in the etiology of SCI over the past fifteen years, including a significant decrease in gunshot wounds and an increase in the frequency of road traffic injuries and falls. These changes and accompanying risk factors must be taken into consideration when planning measures to prevent SCI.

Standardization of an experimental model of intradural injection after spinal cord injury in rats.

OBJECTIVES: The intrathecal route has not yet been thoroughly standardized and evaluated in an experimental model of spinal cord injury (SCI) in Wistar rats. The objective of this study was to standardize and evaluate the effect of intradural injection in this animal model. METHOD: The animals were divided into 6 groups: 1) laminectomy and intradural catheter; 2) laminectomy, intradural catheter and infusion; 3) only SCI; 4) SCI and intradural catheter; 5) SCI, intradural catheter and infusion; and 6) control (laminectomy only). Motor evaluations were performed using the Basso, Beattie and Bresnahan (BBB) scale and the horizontal ladder test; motor evoked potentials were measured for functional evaluation, and histological evaluation was performed as well. All experimental data underwent statistical analysis. RESULTS: Regarding motor evoked potentials, the groups with experimental SCI had worse results than those without, but neither dural puncture nor the injection of intrathecal solution aggravated the effects of isolated SCI. Regarding histology, adverse tissue effects were observed in animals with SCI. On average, the BBB scores had the same statistical behaviour as the horizontal ladder results, and at every evaluated timepoint, the groups without SCI presented scored significantly better than those with SCI (p<0.05). The difference in performance on motor tests between rats with and without experimental SCI persisted from the first to the last test. CONCLUSIONS: The present work standardizes the model of intradural injection in experimental SCI in rats. Intrathecal puncture and injection did not independently cause significant functional or histological changes.

Use and misuse of biomarkers and the role of D-dimer and C-reactive protein in the management of COVID-19: A post-hoc analysis of a prospective cohort study.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) is associated with high mortality among hospitalized patients and incurs high costs. Severe acute respiratory syndrome coronavirus 2 infection can trigger both inflammatory and thrombotic processes, and these complications can lead to a poorer prognosis. This study aimed to evaluate the association and temporal trends of D-dimer and C-reactive protein (CRP) levels with the incidence of venous thromboembolism (VTE), hospital mortality, and costs among inpatients with COVID-19. METHODS: Data were extracted from electronic patient records and laboratory databases. Crude and adjusted associations for age, sex, number of comorbidities, Sequential Organ Failure Assessment score at admission, and D-dimer or CRP logistic regression models were used to evaluate associations. RESULTS: Between March and June 2020, COVID-19 was documented in 3,254 inpatients. The D-dimer level ≥4,000 ng/mL fibrinogen equivalent unit (FEU) mortality odds ratio (OR) was 4.48 (adjusted OR: 1.97). The CRP level ≥220 mg/dL OR for death was 7.73 (adjusted OR: 3.93). The D-dimer level ≥4,000 ng/mL FEU VTE OR was 3.96 (adjusted OR: 3.26). The CRP level ≥220 mg/dL OR for VTE was 2.71 (adjusted OR: 1.92). All these analyses were statistically significant (p<0.001). Stratified hospital costs demonstrated a dose-response pattern. Adjusted D-dimer and CRP levels were associated with higher mortality and doubled hospital costs. In the first week, elevated D-dimer levels predicted VTE occurrence and systemic inflammatory harm, while CRP was a hospital mortality predictor. CONCLUSION: D-dimer and CRP levels were associated with higher hospital mortality and a higher incidence of VTE. D-dimer was more strongly associated with VTE, although its discriminative ability was poor, while CRP was a stronger predictor of hospital mortality. Their use outside the usual indications should not be modified and should be discouraged.

Experience with different botulinum toxins for the treatment of refractory neurogenic detrusor overactivity.

PURPOSE: To report our experience with the use of the botulinum toxin-A (BoNT/A) formulations Botox and Prosigne in the treatment of neurogenic detrusor overactivity (NDO). MATERIALS AND METHODS: At a single institution, 45 consecutive patients with refractory urinary incontinence due to NDO received a single intradetrusor (excluding the trigone) treatment with botulinum toxin type A 200 or 300 units. Botox was used for the first 22 patients, and Prosigne for the subsequent 23 patients. Evaluations at baseline and week 12 included assessment of continence and urodynamics. Safety evaluations included monitoring of vital signs, hematuria during the procedure, hospital stay, and spontaneous adverse event reports. RESULTS: A total of 42 patients were evaluated (74% male; mean age, 34.8 years). Significant improvements from baseline in maximum cystometric capacity (MCC), maximum detrusor pressure during bladder contraction, and compliance were observed in both groups (P < 0.05). Improvement in MCC was significantly greater with Botox versus Prosigne (+103.3% vs. +42.2%; P = 0.019). Continence was achieved by week 12 in 16 Botox recipients (76.2%) and 10 Prosigne recipients (47.6%; P = 0.057). No severe adverse events were observed. Mild adverse events included 2 cases of transient hematuria on the first postoperative day (no specific treatment required), and 3 cases of afebrile urinary tract infection. CONCLUSIONS: Botox and Prosigne produce distinct effects in patients with NDO, with a greater increase in MCC with Botox. Further evaluation will be required to assess differences between these formulations.

Prediction of intensive care admission and hospital mortality in COVID-19 patients using demographics and baseline laboratory data

Abstract Introduction: Optimized allocation of medical resources to patients with COVID-19 has been a critical concern since the onset of the pandemic. Methods: In this retrospective cohort study, the authors used data from a Brazilian tertiary university hospital to explore predictors of Intensive Care Unit (ICU) admission and hospital mortality in patients admitted for COVID-19. Our primary aim was to create and validate prediction scores for use in hospitals and emergency departments to aid clinical decisions and resource allocation. Results: The study cohort included 3,022 participants, of whom 2,485 were admitted to the ICU; 1968 survived, and 1054 died in the hospital. From the complete cohort, 1,496 patients were randomly assigned to the derivation sample and 1,526 to the validation sample. The final scores included age, comorbidities, and baseline laboratory data. The areas under the receiver operating characteristic curves were very similar for the derivation and validation samples. Scores for ICU admission had a 75% accuracy in the validation sample, whereas scores for death had a 77% accuracy in the validation sample. The authors found that including baseline flu-like symptoms in the scores added no significant benefit to their accuracy. Furthermore, our scores were more accurate than the previously published NEWS-2 and 4C Mortality Scores. Discussion and conclusions: The authors developed and validated prognostic scores that use readily available clinical and laboratory information to predict ICU admission and mortality in COVID-19. These scores can become valuable tools to support clinical decisions and improve the allocation of limited health resources.

Standardization of an experimental model of intradural injection after spinal cord injury in rats

OBJECTIVES: The intrathecal route has not yet been thoroughly standardized and evaluated in an experimental model of spinal cord injury (SCI) in Wistar rats. The objective of this study was to standardize and evaluate the effect of intradural injection in this animal model. METHOD: The animals were divided into 6 groups: 1) laminectomy and intradural catheter; 2) laminectomy, intradural catheter and infusion; 3) only SCI; 4) SCI and intradural catheter; 5) SCI, intradural catheter and infusion; and 6) control (laminectomy only). Motor evaluations were performed using the Basso, Beattie and Bresnahan (BBB) scale and the horizontal ladder test; motor evoked potentials were measured for functional evaluation, and histological evaluation was performed as well. All experimental data underwent statistical analysis. RESULTS: Regarding motor evoked potentials, the groups with experimental SCI had worse results than those without, but neither dural puncture nor the injection of intrathecal solution aggravated the effects of isolated SCI. Regarding histology, adverse tissue effects were observed in animals with SCI. On average, the BBB scores had the same statistical behaviour as the horizontal ladder results, and at every evaluated timepoint, the groups without SCI presented scored significantly better than those with SCI (p<0.05). The difference in performance on motor tests between rats with and without experimental SCI persisted from the first to the last test. CONCLUSIONS: The present work standardizes the model of intradural injection in experimental SCI in rats. Intrathecal puncture and injection did not independently cause significant functional or histological changes.

Use and misuse of biomarkers and the role of D-dimer and C-reactive protein in the management of COVID-19: A post-hoc analysis of a prospective cohort study

OBJECTIVE: Coronavirus disease 2019 (COVID-19) is associated with high mortality among hospitalized patients and incurs high costs. Severe acute respiratory syndrome coronavirus 2 infection can trigger both inflammatory and thrombotic processes, and these complications can lead to a poorer prognosis. This study aimed to evaluate the association and temporal trends of D-dimer and C-reactive protein (CRP) levels with the incidence of venous thromboembolism (VTE), hospital mortality, and costs among inpatients with COVID-19. METHODS: Data were extracted from electronic patient records and laboratory databases. Crude and adjusted associations for age, sex, number of comorbidities, Sequential Organ Failure Assessment score at admission, and D-dimer or CRP logistic regression models were used to evaluate associations. RESULTS: Between March and June 2020, COVID-19 was documented in 3,254 inpatients. The D-dimer level ≥4,000 ng/mL fibrinogen equivalent unit (FEU) mortality odds ratio (OR) was 4.48 (adjusted OR: 1.97). The CRP level ≥220 mg/dL OR for death was 7.73 (adjusted OR: 3.93). The D-dimer level ≥4,000 ng/mL FEU VTE OR was 3.96 (adjusted OR: 3.26). The CRP level ≥220 mg/dL OR for VTE was 2.71 (adjusted OR: 1.92). All these analyses were statistically significant (p<0.001). Stratified hospital costs demonstrated a dose-response pattern. Adjusted D-dimer and CRP levels were associated with higher mortality and doubled hospital costs. In the first week, elevated D-dimer levels predicted VTE occurrence and systemic inflammatory harm, while CRP was a hospital mortality predictor. CONCLUSION: D-dimer and CRP levels were associated with higher hospital mortality and a higher incidence of VTE. D-dimer was more strongly associated with VTE, although its discriminative ability was poor, while CRP was a stronger predictor of hospital mortality. Their use outside the usual indications should not be modified and should be discouraged.

Lead poisoning by intradiscal firearm bullet: a case report.

STUDY DESIGN: The report of a rare case of lead poisoning by an intradiscal firearm bullet is presented. OBJECTIVE: To describe and discuss the clinical and radiologic features (by computed tomography and magnetic resonance imaging) of a gunshot wound in the L2-L3 space which caused lead poisoning 5 years afterwards. SUMMARY OF BACKGROUND DATA: Lead poisoning from firearm bullets is rare, but the possibility should be investigated in the case of bullets lodged in the joints. METHODS: A 30-year-old man presented to the emergency room with an intense lumbar pain complaint, colic, intestinal constipation, insomnia, and progressive headache for 20 days. He had a history of a gunshot wound 5 years previously, and the bullet was left in situ, in the intravertebral disc between L2 and L3, as confirmed by radiographs, computed tomography, and magnetic resonance imaging. The hypothesis of lead poisoning was confirmed by the laboratory results. Chelation treatment with calcium versenate (disodium ethylenediaminetetraacetate, or CaNa (2) EDTA) was indicated. The patient was admitted and treated once again, before surgical removal of the bullet. RESULTS: After removal of the bullet, the patient had an episode of recurrence, and a new chelation cycle was performed, with complete resolution. CONCLUSION: Lead poisoning can result in severe clinical disorders that require rapid treatment. In this case, both clinical and surgical treatments led to complete resolution of the symptoms.

Transplante autólogo de condrócitos: relato de três casos / Autologous chondrocyte implantation: series of 3 cases

A cartilagem hialina recobre as superfícies articulares e tem um papel importante na redução da fricção e da carga mecânica das articulações sinoviais, como o joelho. Este tecido não é suprido de vasos, nervos ou circulação linfática, o que pode ser uma das razões pela qual a cartilagem articular tem uma péssima capacidade de cicatrização. As lesões condrais, quando atingem o osso subcondral (lesão osteocondral), não cicatrizam e podem progredir para artrose com o passar do tempo. Em pacientes jovens, o tratamento dos defeitos condrais do joelho ainda é um desafio, principalmente as lesões maiores de 4cm. Uma das opções de tratamento nesses pacientes é o transplante autólogo de condrócitos, que por não violar o osso subcondral e por reparar o defeito com tecido semelhante à cartilagem hialina, teria a vantagem teórica de ser mais biológico e mecanicamente superior, quando comparado a outras técnicas. Descreveremos nesse artigo a experiência do Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Universidade de São Paulo (IOT-HCFMUSP) com o transplante autólogo de condrócitos (ACI), através do relato de três casos.

Hyaline cartilage in the surface of synovial joints plays an important role in lowering stress and attrition in joints such as the knee. This tissue has no blood vessels, nerves, nor lymphatic drainage, which in part explains why articular cartilage has such poor capacity for healing. Chondral lesions reaching the subchondral bone (osteochondral lesions) do not heal and may progress to osteoarthritis as time passes. In young patients, treatment of such defects is challenging, especially in lesions larger than 4 cm. One option in young adults is the autologous chondrocyte implantation, capable of filling the defect with tissue similar to hyaline cartilage without violating the subchondral bone. Theoretically, it has biological and mechanical advantages over other surgical options. In this paper, we describe the experience with this procedure in a series of 3 cases at the Institute of Orthopedics and Traumatology, University of São Paulo.

Experience with different botulinum toxins for the treatment of refractory neurogenic detrusor overactivity

Purpose: To report our experience with the use of the botulinum toxin-A (BoNT/A) formulations Botox® and Prosigne® in the treatment of neurogenic detrusor overactivity (NDO). Materials and methods: At a single institution, 45 consecutive patients with refractory urinary incontinence due to NDO received a single intradetrusor (excluding the trigone) treatment with botulinum toxin type A 200 or 300 units. Botox was used for the first 22 patients, and Prosigne for the subsequent 23 patients. Evaluations at baseline and week 12 included assessment of continence and urodynamics. Safety evaluations included monitoring of vital signs, hematuria during the procedure, hospital stay, and spontaneous adverse event reports. Results: A total of 42 patients were evaluated (74 percent male; mean age, 34.8 years). Significant improvements from baseline in maximum cystometric capacity (MCC), maximum detrusor pressure during bladder contraction, and compliance were observed in both groups (P < 0.05). Improvement in MCC was significantly greater with Botox versus Prosigne (+103.3 percent vs. +42.2 percent; P = 0.019). Continence was achieved by week 12 in 16 Botox recipients (76.2 percent) and 10 Prosigne recipients (47.6 percent; P = 0.057). No severe adverse events were observed. Mild adverse events included 2 cases of transient hematuria on the first postoperative day (no specific treatment required), and 3 cases of afebrile urinary tract infection. Conclusions: Botox and Prosigne produce distinct effects in patients with NDO, with a greater increase in MCC with Botox. Further evaluation will be required to assess differences between these formulations.

A utilização do tubo de ácido poliglicólico e FK506 na regeneração de nervos periféricos / Use of polyglicolic acid tube associated with FK506 in regeneration of peripheral nerves

Grandes perdas de tecido neural não permitem a reparação através de anastomose primária. Nesses casos, a auto-enxertia de nervo é considerada tratamento de escolha. O tubo sintético à base de ácido poliglicólico é uma opção para enxertia de nervo. O FK506 é um imunossupressor que aumenta a taxa de regeneração neural "in vivo" e "in vitro". O objetivo deste trabalho foi comparar, em ratos, o grau de regeneração neural, utilizando análise histológica, contagem do número de axônios mielinizados regenerados e análise funcional, obtida com a interposição de enxerto autógeno (grupo A), tubo de ácido poliglicólico (grupo B) e da associação do tubo de ácido poliglicólico à administração de FK506 (grupo C) em defeitos de 5 mm no nervo ciático. Foi observado a formação de neuroma apenas no grupo A. Os grupos B e C apresentaram padrões histológicos semelhantes. A avaliação quantitativa do número de axônios mielinizados regenerados determinou que: 1) o grupo B apresentou em média um menor número em ralação aos demais grupos; 2) não houve diferença significativa entre o grupo controle A e o grupo C. Na recuperação funcional, não houve diferença estatisticamente significativa entre os três grupos, a despeito das diferenças histológicas qualitativas e quantitativas verificadas.

Epidemiologia e tratamento das úlceras de pressão: experiência de 77 casos / Epidemiological profile and treatment of pressure sores: experience with 77 cases

Ulceras de pressão são úlceras decorrentes de isquemia tecidual provocadas pela alteração do reflexo de dor em pacientes com lesão medular, pacientes debilitados, idosos ou cronicamente doentes. No Brasil, poucos estudos vem sendo realizados a respeito das úlcera de pressão e seu tratamento. O objetivo desse trabalho é avaliar a distribuição epidemiológica, o tratamento e complicaçòes das úlceras de pressão no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, no período de 01 de fevereiro de 1997 a 01 de março de 1999 no Instituto de Ortopedia e Traumatologia. Um estudo prospectivo foi realizado neste período através de um protocolo que avaliava sexo, idade, fatores de risco, localização, dimensões, classificação das úlceras, tipo de tratamento, complicações pós-operatórias, tempo de internação e cronicidade da úlcera. O tratamento era avaliado através da taxa de sucesso e recorrência. O tempo de seguimento médio foi de 1 ano e 6 meses. (6 meses a 2 anos). Com 45 pacientes com 77 úlceras foram avaliados neste período. Em relação ao sexo , foi encontrada uma predomibância masculina 4:1. 32,47 por cento das úlceras tiveram sua localização em região sacral e 32,47 por cento trocantérica e 15,58 por cento isquiáticas. Na maioria jovem (média de 34,78 anos), com lesão medular (100 por cento dos pacientes), vítimas de lesões por arma de fogo (60 por cento dos pacientes), de caráter crônico (93,3 por cento) e lesão grau IV (67,53 por cento). As úlceras trocantéricas possuiam dimensões maiores (9,5 cm). 77,92 por cento das úlceras de pressão foram tratadas cirurgicamente, com predomínio dos retalhos miocutâneos (45 por cento) . Em relação a avaliação do tratamento temos: a taxa de sucesso do tratamento das úlcera de pressão foi de 80 por cento trocantérica, 84 por cento sacral e 66,6 por cento isquiática. A taxa de recorrência foi de 25 por cento. A taxa de complicação variou segundo a localização: úlcera trocantérica 84 por cento, 50 por cento isquiática e 64 por cento sacral.

Angiossarcoma epitelióide ósseo: relato de um caso, com estudo imuno-histoquímico / Epithelioid angiosarcoma of bone: report of a case with immunohistochemical study

Angiossarcoma primário do osso é muito raro, representando menos de 1 por cento de todos os angiossarcomas. Neoplasias vasculares também são incomuns, ocorrendo em 14 por cento dos tumores malignos primários do osso. Os autores relatam caso em coluna lombar que merece atenção porque inicialmente tratava-se de um hemangioendotelioma, um tumor de malignidade intermediária, definido pelos critérios estabelecidos por Stout. Foi tratado com embolização local e radioterapia. Após dez anos, recidivou, com maior grau de malignidade, fenômeno interpretado como progressão tumoral, com caracterísitcas de Angiossarcoma epitelióide. O estudo imuno-histoquímico revelou positividade para marcadores vasculares (Fator VIII, CD31 e CD34). O paciente evoluiu com metástases pulmonares. Em revisão bibliográfica, não foi encontrado nenhum relato de caso semelhante, tendo em vista a longa evolução e progressão tumoral após dez anos de seguimento e expressão do fenotipo epitelióide.

A artrite reumatóide e a coluna cervical / Rheumatoid arthritis and the cervical spine

A artrite reumatóide pode lesar as articulaçöes, ligamentos e ossos da coluna cervical, podendo ocasionar: subluxaçäo atlanto-axial, impacçäo atlanto-axial e subluxaçäo subaxial. Em geral o tratamento conservador é o preferido, mas há indicaçöes para tratamento cirúrgico nas seguintes subluxaçöes: 1) déficit neurológico importante, especialmente quando progressivo; 2) dor intensa; 3) grandes instabilidades. Os autores apresentam 15 casos de artrite reumatóide acometendo a coluna cervical que foram tratados cirurgicamente, sendo cinco subluxaçöes atlanto-axiais, duas impacçöes atlanto-axiais e oito subluxaçöes subaxiais

Complicacoes da cirurgia de hernia discal / Complications of herniated disk surgery

O autor faz uma revisao da literatura sobre as complicacoes que podem ocorrer na cirurgia da coluna lombar em especial na cirurgia da hernia discal. Sao revistas as causas e as complicacoes pre-operatorias, operatorias, pos-operatorias imediatas e pos-operatorias tardias. O autor faz comentarios sobre os possiveis fatores que mantem altos os indices de maus resultados cirurgicos, apesar do progresso no diagnostico das diversas patologias da coluna-sacra.

Estudo expirimental comparativo da flexäo entre duas técnicas de estabilizaçäo da coluna cervical de Rogers e Bohlman / Comparative experimental study of cervical spine flexion by Rogers and Bohlman techniques of stabilization

Existem diversas maneiras de fixar a coluna cervical instavél por via posterior. Testaram-se através de ensaios de flexäo 20 peças anatômicas de coluna cervical, obtidas de cadáveres humanos, divididas em dois grupos distintos quanto ao modo de fixaçäo da coluna cervical, técnica de Rogers ou de Boalman. Em todas as colunas foi criada uma instabilidade tipo traçäo-flexäo entre a quinta e a sexta vértebras cervicais. Os ensaios foram realizado em máquina universal de ensaios mecânicos com dispositivo apropriado. Este estudo revelou que a técnica de Bohlman é mais segura, protegendo melhor o local de instabilidade da coluna cervical. Quanto ao desvio angular, a rigidez e o limite de ruptura, näo houve diferença estatística significante entre as duas técnicas testadas.

Diagnóstico por imagem nas lombalgias / Diagnostic imaging in backaches

Os autores avaliam as várias modalidades de diagnóstico empregadas nas lombalgias. Analisam as modalidades de diagnóstico em relaçäo ao quadro clínico. Apresentam um algoritmo baseado na idade dos pacientes

Corpectomy and anterior plating in cervical spine fractures with tetraplegia

Between 1980 and 1989, 68 tetraplegic patients (69 males and 8 females) with cervical spine fractures were treated with corpectomy, iliac bone grafting and anterior plating. The average age was 27 years (15-58 years). The resected vertebrae was C4 in 4 cases, C5 in 24, C6 in 32 and C7 in 8. The injuries were classified according to Allen et al. in: compressive flexion in 47 cases, vertical compression in 20 and distractive flexion in 1. The neurologic deficit was complete in 30 patients and incomplete in 38 patients. The surgery was performed 7 days (average) (1-28 days) after the trauma. The mean follow-up was 2.8 years (1-9 years). In the postoperative period early mobilization was permitted with a plastic collar. There were 6 deaths that were not related to the technique in the first 4 weeks; the results of the remaining 62 patients are presented hereafter. In the final follow-up we observed that 56 patients had no complications related to the procedure and the spine was stabilized. The following complications were observed in the remaining patients: 5 partial loosening of the plate, but the patients were asymptomatic and 1 complete loosening that was reoperated after 2 weeks. The motor indices improved from 12.4 points initially to 23.7 in the complete tetraplegics and from 30.2 points to 72.5 in the incomplete tetraplegics. We conclude that the anterior plate fixation after anterior decompression for cervical spine fractures avoids the extrusion of the graft and provides immediate stabilization of the spine, permitting early mobilization of the patients.