Patients' and Clinicians' Experiences with In-person, Video, and Phone Modalities for Opioid Use Disorder Treatment: A Qualitative Study.

BACKGROUND: Opioid use disorder (OUD) is a chronic condition that requires regular visits and care continuity. Telehealth implementation has created multiple visit modalities for OUD care. There is limited knowledge of patients' and clinicians' perceptions and experiences related to multi-modality care and when different modalities might be best employed. OBJECTIVE: To identify patients' and clinicians' experiences with multiple visit modalities for OUD treatment in primary care. DESIGN: Comparative case study, using video- and telephone-based semi-structured interviews. PARTICIPANTS: Patients being treated for OUD (n = 19) and clinicians who provided OUD care (n = 15) from two primary care clinics within the same healthcare system. APPROACH: Using an inductive approach, interviews were analyzed to identify patients' and clinicians' experiences with receiving/delivering OUD care via different visit modalities. Clinicians' and patients' experiences were compared using a group analytical process. KEY RESULTS: Patients and clinicians valued having multiple modalities available for care, with flexibility identified as a key benefit. Patients highlighted the decreased burden of travel and less social anxiety with telehealth visits. Similarly, clinicians reported that telehealth decreased medical intrusion into the lives of patients stable in recovery. Patients and clinicians saw the value of in-person visits when establishing care and for patients needing additional support. In-person visits allowed the ability to conduct urine drug testing, and to foster relationships and trust building, which were more difficult, but not impossible via a telehealth visit. Patients preferred telephone over video visits, as these were more private and more convenient. Clinicians identified benefits of video, including being able to both hear and see the patient, but often deferred to patient preference. CONCLUSIONS: Considerations for utilization of visit modalities for OUD care were identified based on patients' needs and preferences, which often changed over the course of treatment. Continued research is needed determine how visit modalities impact patient outcomes.

Application of a novel chemical assay for the quantification of endotoxins in bacterial bioreactor samples.

A novel chemical assay, the so-called Kdo-DMB-liquid chromatography (LC) assay, was used for the accurate and cost-effective determination of the endotoxin content in supernatants of Gram-negative bacteria bioreactor samples. During mild acid hydrolysis, the endotoxin-specific sugar acid 3-deoxy-D-manno-oct-2-ulsonic acid (Kdo) is quantitatively released. Kdo is reacted with 1,2-diamino-4,5-methylenedioxybenzene (DMB) to obtain the highly fluorescent derivate Kdo-DMB. It is separated from the reaction mixture by reversed phase-(U)HPLC and detected by fluorescence. From the Kdo content the endotoxin content of the sample is calculated. For three batch cultivations of Escherichia coli K12 and a fed-batch cultivation of Pseudomonas putida KT2440, the evolution of the endotoxin content in dependence on the cultivation time was monitored. Under optimal, constant cultivation conditions a linear correlation between the endotoxin content and the easy-to-access bioreactor parameters optical density at 600 nm and dry cell weight was found for both endotoxin kinds. Under stress cultivation conditions the E. coli K12 cultivation showed a stronger increase of the endotoxin content at harvest in comparison to optimal conditions. Optical density and dry cell weight may be used for production reactors as an economic real-time estimation tool to determine the endotoxin content at different cultivation time points and conditions. The optical density can further be used to establish straightforward sample dilution schemes for endotoxin quantification in samples of unknown endotoxin content. The endotoxin content [ng mL-1] measured by the Kdo-DMB-LC assay and the endotoxin activity [EU mL-1] obtained by the compendial Limulus Amoebocyte Lysate assay show a high correlation for the bacterial bioreactor samples tested.

Realistic operation of two residential cordwood-fired outdoor hydronic heater appliances-Part 2: Particle number and size.

The use of wood as a fuel for home heating is a concern from an environmental health and safety perspective as biomass combustion appliances emit high concentrations of particulate matter. Wood burning significantly contributes to wintertime particulate matter concentrations in many states in the northern United States. Of particular concern are outdoor wood-fired hydronic heaters. These devices are concerning as they tend to have very large combustion chambers and typical use patterns can result in long periods of low output, which result in an increased particulate matter emission rate relative to high heat output operating conditions. In this study, the performance of two hydronic heaters operating under different combustion conditions, including four different heat output categories approximately corresponding to categories I-IV denoted in Environmental Protection Agency Method 28 Outdoor Wood-fired Hydronic Heaters, and during start-up and reloading events were investigated. Measurements of flue gas particulate number concentration and size for particles with aerodynamic diameters between 0.006 and 10 µm were made using a dilution sampling system. The measured particle number concentration in the flue gas was between 0.71 and 420 million particles per cubic centimeter and was dependent on fuel loading and heat output. For each hydronic heater tested, the highest average particle concentration was found at the beginning of each test during the cold-start condition. Additionally, the majority of the particles had aerodynamic diameters less than 0.100 µm (particles of this size made up between 64% and 97% of all particles) and less than 1% of all particles had aerodynamic diameters greater than 1 µm for all phases. For particles in the accumulation mode, between 0.100 and 1 µm, the mean particle diameter was dependent on fuel loading and heat output.Implications: In this work, we provide information on the particle number concentration and particle size of emissions from outdoor cord- wood-fired hydronic heaters. Wood-fired hydronic heater data is sparsely available compared to wood stove data. Thus, additional data from this source help to inform the work of modelers and policy makers interested in hydronic heaters. The test method used in this work is also novel, as it is more inclusive of real-world use cases than the current certification method. Our data helps to validate the test method and allows for comparisons between real-world use case scenarios, and idealized test cases.

Characterization of in-stack particulate emissions from residential wood hydronic heater appliances under different combustion conditions.

In the current work, we provide measurements of size-resolved particle number concentration (PNC), particle mass concentration (PMC), lung-deposited surface area (LDSA), and black carbon (BC) concentration for three biomass fired hydronic heaters during operation in four different combustion conditions. The appliances include one woodchip-fueled hydronic heater and two outdoor cordwood-fueled hydronic heaters. The operating conditions included startup, low output, high output, and burnout. Measurements were made using a custom dilution sampling system and a suite of commercially available, time-resolved, ambient aerosol measurement instrumentation. The PNC, as measured using an Dekati Electrical Low Pressure Impactor+ (ELPI), had operating condition mean values ranging between 4.1 and 52 million particles per cubic centimeter (#/cm3). The highest reported PNC occurred during the startup condition in all cases. Calculating the particle size distribution measured across each operating phase for the same instrument gave geometric mean diameters (dg) in the range of 0.080-0.256 µm. The largest dg per appliance was nearly always attributable to the startup condition (for hydronic heater 1, startup dg ranked second).We did not observe the same trends when we transformed the ELPI PNC to PMC and particle surface area concentration estimates across operating conditions, suggesting PNC and dg are highly variable. Furthermore, simultaneous measurements of PNC, PMC, and PSAC using instrumentation with different working principles gave varying results, potentially suggesting that particles of different composition and morphology are produced under different combustion conditions.Implications: In this work we compare the results from testing of 3 biomass fired hydronic heaters including one chip-fired appliance and two cordwood-fired appliances. The emissions from these appliances were made across four operating conditions and using three different non-regulatory emissions metrics. This work: describes the difference between chip and cordwood fired units and the effect of operating condition on emissions across the three emissions metrics.

Realistic operation of two residential cordwood-fired outdoor hydronic heater appliances-Part 3: Optical properties of black and brown carbon emissions.

Residential biomass combustion is a source of carbonaceous aerosol. Inefficient combustion, particularly of solid fuels produces large quantities of black and brown carbon (BC and BrC). These particle types are important as they have noted effects on climate forcing and human health. One method of measuring these quantities is by measurement of aerosol light-absorption and scattering, which can be performed using an aethalometer and nephelometer, respectively. These instruments are widely deployed in the study of ambient air and are frequently used in air quality modeling and source apportionment studies. In this study, we will describe (1) a method for measuring primary BC and BrC emissions from two residential log-fired wood hydronic heaters and (2) the BC and BrC emission from these devices over a wide range of operating conditions, such as cold-starts, warm-starts, four different levels of output ranging from 15% to 100% maximum rated output, and periods of repeated cycling. The range in flue-gas BC concentrations, measured using an aethalometer at the 880 nanometer (nm) wavelength, were between 5.09 × 102 and 2.24 × 104 micrograms per cubic meter (µg/m3) while the scattering coefficient of the flue-gas, measured by a nephelometer at 880 nm, ranged between 2.20 × 103 and 8.56 × 105 inverse megameters (Mm-1). The BrC concentrations, measured using the 370 nm wavelength of an aethalometer, were between 9.10 × 101 and 3.56 × 104 µg/m3. The calculated Angstrom Absorption Exponent (AAE) of the flue-gas aerosol ranged between 1.54 and 3.63. Performing a comparison between the measured BC concentration and an external particulate matter (PM) concentration showed that overall BC makes up roughly a quarter of the PM emitted by either of the two appliances. Further for both appliances, the cold-start and the test phase immediately following it had the highest BC and BrC concentrations, the highest measured scattering coefficient, as well as a low AAE.Implications: In this work we provide information on the black and brown carbon emissions from outdoor cordwood-fired hydronic heaters. Aethalometer based black carbon measurements are common in atmospheric science, but are uncommonly used in laboratory studies. This work helps to bridge that gap. This data helps to inform the work of modelers and policy makers interested in hydronic heaters and source apportioning biomass combustion emissions.

Feasibility of supercritical fluid extraction-supercritical fluid chromatography mass spectrometry for the determination of polycyclic aromatic hydrocarbons in particulate matter samples.

There has been an increased interest in the development of green analytical methods for polycyclic aromatic hydrocarbons in environmental samples due to their toxicity and ubiquitous nature. In this work, the feasibility of on-line supercritical fluid extraction-supercritical fluid chromatography-tandem mass spectrometry was investigated for rapid and automated determination of the 16 United States Environmental Protection Agency priority polycyclic aromatic hydrocarbons in particulate matter samples. Three specialty polycyclic aromatic hydrocarbons columns with different stationary phases were screened and an octadecyl-silica column was selected for method development. Enhanced extraction efficiency was achieved using an extraction program with gradient flow rate and gradient concentration of acetonitrile as a modifier. The method was evaluated by analyzing standard reference materials of urban dust and diesel particulate matter from the National Institute of Standards and Technologies. Possible reasons for the unsatisfactory recoveries with certain polycyclic aromatic hydrocarbons are discussed.

Novel RP-HPLC based assay for selective and sensitive endotoxin quantification.

The paper presents a novel instrumental analytical endotoxin quantification assay. It uses common analytical laboratory equipment (HPLC-FLD) and allows quantifying endotoxins (ETs) in different matrices from about 109 EU per mL down to about 40 EU per mL (RSE based). Test results are obtained in concentration units (e.g. ng ET per mL), which can then be converted to commonly used endotoxin units (EU per mL) in case of known pyrogenic activity. During endotoxin hydrolysis, the endotoxin specific rare sugar acid KDO is obtained quantitatively. After that, KDO is stoichiometrically reacted with DMB, which results in a highly fluorescent derivative. The mixture is separated using RP-HPLC followed by KDO-DMB quantification with a fluorescence detector. Based on the KDO content, the endotoxin content in the sample is calculated. The developed assay is economic and has a small error. Its applicability was demonstrated in applied research. ETs were quantified in purified bacterial biopolymers, which were produced by Gram-negative bacteria. Results were compared to LAL results obtained for the same samples. A high correlation was found between the results of both methods. Further, the new assay was utilized with high success during the development of novel endotoxin specific depth filters, which allow efficient, economic and sustainable ET removal during DSP. Those examples demonstrate that the new assay has the potential to complement the animal-based biological LAL pyrogenic quantification tests, which are accepted today by the major health authorities worldwide for the release of commercial pharmaceutical products.

Health Equity and the Tripartite Mission: Moving From Academic Health Centers to Academic-Community Health Systems.

Academic health centers (AHCs) play a significant role in educating the health care workforce, conducting innovative biomedical and clinical research, and delivering high-quality patient care. Much work remains, however, to adequately address the social determinants of health and equity that affect communities where patients live, work, and play. Doing so will help achieve the Quadruple Aim while addressing the unjust social structures that disproportionately impact communities of color and vulnerable populations. AHCs have a timely opportunity to focus their leading roles in education, research, and clinical care on social determinants, moving outside their walls to create academic-community health systems: a collection of academic-community partnerships advancing health equity through collaboration, power sharing, and cocreation.This Perspective proposes four strategies to start developing academic-community health systems. First, embark on all efforts through cocreation with communities. Second, address how future health care professionals are recruited. Third, build the right skills and opportunities for health care professionals to address health inequities. Finally, develop research agendas to evaluate programs addressing inequities. A fully realized vision of an academic-community health system will demonstrate interdependence between AHCs and the community. While considerable AHC resources are invested in building community capacity to improve health and health equity, health systems will also benefit in a multitude of ways, including increasing the diversity of ideas and experiences integrated into health systems. These strategies will support AHCs to embed across each arm of the tripartite mission a focus on partnering with communities to advance health equity together.

Addressing Family Medicine's Capacity to Improve Health Equity Through Collaboration, Accountability and Coalition-Building.

Achieving health equity requires an evaluation of social, economic, environmental, and other factors that impede optimal health for all. Family medicine has long valued an ecological perspective of health, partnering with families and communities. However, both the quantity and degree of continued health disparities requires that family medicine intentionally work toward improvement in health equity. In recognition of this, Family Medicine for America's Health (FMAHealth) formed a Health Equity Tactic Team (HETT). The team's charge was to address primary care's capacity to improve health equity by developing action-oriented approaches accessible to all family physicians. The HETT has produced a number of projects. These include the Starfield II Summit, the focus of which was "Primary Care's Role in Achieving Health Equity." Multidisciplinary thought leaders shared their work around health equity, and actionable interventions were developed. These formed the basis of subsequent work by the HETT. This includes the Health Equity Toolkit, designed for a broad interdisciplinary audience of learners to learn to improve care systems, reduce disparities, and improve patient outcomes. The HETT is also building a business case for health equity. This has focused efforts on demonstrating to the private sector an economic argument for health equity. The HETT has formed a close partnership with the American Academy of Family Physicians' (AAFP's) Center for Diversity and Health Equity (CDHE), collaborating on numerous efforts to increase awareness of health equity. The team has also focused on engaging leadership in all eight US national family medicine organizations to participate in its activities and to ensure that health equity remains a top priority in its leadership. Looking ahead, family medicine will be required to continuously engage with government and nongovernment agencies, academic centers, and the private sector to create partnerships to systematically tackle health inequities.

Feasibility of Using a Community-Supported Agriculture Program to Increase Access to and Intake of Vegetables among Federally Qualified Health Center Patients.

OBJECTIVE: This study explored the feasibility of using a 23-week subsidized community-supported agriculture program to increase access to and intake of vegetables among Federally Qualified Health Center patients. METHODS: Outcomes were measured using pre-post intervention surveys (n = 9). Process data were collected in post-intervention surveys and focus groups (n = 15). RESULTS: Most participants (77%) indicated that the program improved their health and all (100%) reported that they were eating a greater variety of vegetables because of their participation in the program. Three themes emerged from the focus groups: increased access to fresh and/or organic vegetables, improved diet quality, and the importance of social support during the program. CONCLUSIONS AND IMPLICATIONS: Linking subsided community-supported agriculture programs with Federally Qualified Health Centers has the potential to increase access to and intake of vegetables among low-income patients. However, further research is needed with a larger sample size and a more robust study design.

Venous thromboembolism after major venous injuries: Competing priorities.

BACKGROUND: Venous thromboembolism (VTE) after major vascular injury (MVI) is particularly challenging because the competing risk of thrombosis and embolization after direct vessel injury must be balanced with risk of bleeding after surgical repair. We hypothesized that venous injuries, repair type, and intraoperative anticoagulation would influence VTE formation after MVI. METHODS: A multi-institution, retrospective cohort study of consecutive MVI patients was conducted at three urban, Level I centers (2005-2013). Patients with MVI of the neck, torso, or proximal extremities (to elbows/knees) were included. Our primary study endpoint was the development of VTE (DVT or pulmonary embolism [PE]). RESULTS: The 435 major vascular injury patients were primarily young (27 years) men (89%) with penetrating (84%) injuries. When patients with (n = 108) and without (n = 327) VTE were compared, we observed no difference in age, mechanism, extremity injury, tourniquet use, orthopedic and spine injuries, damage control, local heparinized saline, or vascular surgery consultation (all p > 0.05). VTE patients had greater Injury Severity Score (ISS) (17 vs. 12), shock indices (1 vs. 0.9), and more torso (58% vs. 35%) and venous (73% vs. 48%) injuries, but less often received systemic intraoperative anticoagulation (39% vs. 53%) or postoperative enoxaparin (47% vs. 61%) prophylaxis (all p < 0.05). After controlling for ISS, hemodynamics, injured vessel, intraoperative anticoagulation, and postoperative prophylaxis, multivariable analysis revealed venous injury was independently predictive of VTE (odds ratio, 2.7; p = 0.002). Multivariable analysis of the venous injuries subset (n = 237) then determined that only delay in starting VTE chemoprophylaxis (odds ratio, 1.3/day; p = 0.013) independently predicted VTE after controlling for ISS, hemodynamics, injured vessel, surgical subspecialty, intraoperative anticoagulation, and postoperative prophylaxis. Overall, 3.4% of venous injury patients developed PE, but PE rates were not related to their operative management (p = 0.72). CONCLUSION: Patients with major venous injuries are at high risk for VTE, regardless of intraoperative management. Our results support the immediate initiation of postoperative chemoprophylaxis in patients with major venous injuries. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Systemic intraoperative anticoagulation during arterial injury repair: Implications for patency and bleeding.

BACKGROUND: The role of systemic intraoperative anticoagulation (SIAC) during surgical repair of major arterial injuries is controversial. Any potential improvement in arterial patency must be weighed against the risk of hemorrhage in these critically injured patients. We hypothesized that SIAC would increase arterial patency without increasing bleeding complications. METHODS: We conducted a multi-institution, retrospective cohort study of trauma patients with major vascular injury from 2005 to 2013 in three Level I centers. Arterial injuries of the neck, torso, and proximal extremities requiring operative management were included. Our primary endpoint was maintenance of arterial patency during index hospitalization. Complications related to bleeding were assessed. The association between SIAC and arterial patency was evaluated using chi-square, t test, and multiple logistic regression modeling. RESULTS: Of 323 study patients, most were male (88%) and injured by gunshot wounds (69%). Patients repaired with SIAC (n = 154) were compared to those repaired without SIAC (n = 169). No difference in age, gender, mechanism, admission heart rate, or concomitant injury was detected between the groups (all p > 0.05). SIAC use was associated with greater arterial patency rates (93% vs. 85%, p = 0.02) without increasing return to OR for bleeding (4% vs. 6%, p = 0.29). After controlling for gender, admission hemodynamics, ISS, injury location, and postoperative anticoagulation, multivariable regression determined that SIAC patients were 2.6 times more likely (OR 2.6, 95% CI 1.1-6.2, p = 0.03) to maintain patency. Patients who maintained arterial patency were then less likely to return to the OR (9% vs. 78%, p < 0.001) with shorter intensive care unit (median 3 vs. 9 days, p < 0.01) and hospital length of stay (median 13 vs. 21 days, p < 0.01). CONCLUSION: Patients who underwent operative repair of arterial injuries utilizing SIAC experienced better arterial patency without additional bleeding complications as compared to those repaired without SIAC. Our data suggest that SIAC may improve arterial patency rates after repair and the attributable bleeding risk of SIAC may be overstated. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Inducing Therapeutic Hypothermia in Cardiac Arrest Caused by Lightning Strike.

Only limited clinical scenarios are grounds for induction of therapeutic hypothermia. Its use in traumatic cardiac arrests, including those from lightning strikes, is not well studied. Nonshockable cardiac arrest rhythms have only recently been included in resuscitation guidelines. We report a case of full neurological recovery with therapeutic hypothermia after a lightning-induced pulseless electrical activity cardiac arrest in an 18-year-old woman. We also review the important pathophysiology of lightning-induced cardiac arrest and neurologic sequelae, elaborate upon the mechanism of therapeutic hypothermia, and add case-based evidence in favor of the use of targeted temperature management in lightning-induced cardiac arrest.

Improving treadmill performance in patients with lumbar stenosis: evaluation of a custom angle load reduction device.

OBJECTIVE: The aim of this study was to evaluate a custom angle load reduction rolling walker to determine the relationship between flexion and load reduction on walking performance in patients with lumbar spinal stenosis.The hypothesis was that walking performance in patients with lumbar spinal stenosis would be significantly improved using the Oliver Static Measuring Apparatus device compared with unaided treadmill walking. DESIGN: Fifteen patients with symptomatic neurogenic intermittent claudication caused by lumbar spinal stenosis were recruited at a Veterans Affairs Medical Center. This study used a cross-sectional design with two random-order treadmill conditions: (1) spinal flexion and unloading and (2) level walking. Primary outcome measures included initiation time of first symptoms, total walking time, spinal flexion angle, and unloading force. Secondary measures included baseline pain, fatigue, and disability severity. RESULTS: The participants' initiation time of symptoms and total walking time were significantly greater with the use of the Oliver Static Measuring Apparatus compared with the unaided walking trial. The participants with increased baseline pain, fatigue, and disability severity had decreased walking performance for the unaided condition but not for the Oliver Static Measuring Apparatus condition. CONCLUSIONS: The results show that spinal flexion is important for pain reduction in lumbar spinal stenosis. The Oliver Static Measuring Apparatus device used in this study was shown to be effective and immediate in significantly increasing total walking time and prolonging the onset of neurogenic intermittent claudication symptoms while ambulating.

1,2-Di(phenylethynyl)ethenes with axially chiral, 2,2'-bridged 1,1'-binaphthyl substituents: potent cholesteric liquid-crystal inducers.

Axially chiral, 3,5-dihydro-4H-dinaphtho[2,1-c:1',2'-e]azepine (dinaphthazepine) and 1,1'-binaphthyl-2,2'-disulfonimide (dinaphthosulfonimide) moieties were rigidly connected via N-p-phenylene linkers to photochemically (E)/(Z)-isomerisable 1,2-diethynylethene scaffolds. The chemical stability of the resulting systems was found to be critically related to the other substituents on the central π-conjugated scaffold. High helical twisting power (HTP), up to 315 µm(-1), for the induction of a cholesteric liquid-crystalline phase through doping of a nematic phase was measured, resulting from the introduction of the chiral, mesogenic 1,1'-binaphthyl motifs. Single crystal X-ray analysis revealed that the phenylene spacer is in π-conjugation with the N-atom of the dinaphthazepine but not with the N-atom of the dinaphthosulfonimide moiety. This difference in orientation results in visible-transparency in the electronic absorption spectrum and higher (E)/(Z)-photoisomerisation quantum yields of the dinaphthosulfonimide-derived chiral dopants, as compared to the dinaphthazepine systems, which feature intramolecular charge-transfer absorption in the visible region.

Donor-substituted diphenylacetylene derivatives act as electron donors and acceptors.

Despite the predominant electron donor character of p-phenylenediamine, our studies on extended p-phenylenediamine derivatives show that they can not only be chemically oxidized, giving well-known Wurster-type radical cations, but also be chemically reduced, giving radical anions. Making use of EPR/ENDOR spectroscopy and supported by DFT calculations, we were able to reveal the extent of π-electron delocalization in the paramagnetic species and to shed light onto the geometry and bond lengths. While for the radical anions spin was found to be mostly delocalized into the π-system, the radical cations can be described as essentially N-centered. Furthermore, we performed electrochemical characterizations using cyclic voltammetry to gain insight into the thermodynamics of the redox processes. The photophysical properties of the parent extended p-phenylenediamine were investigated by absorption, emission, and excitation spectroscopy. The fluorescence quantum yield and the excited-state lifetime of the neutral precursors in hexane and acetonitrile were determined to establish elementary differences originating from solvent effects.

Neurologic improvement after thoracic, thoracolumbar, and lumbar spinal cord (conus medullaris) injuries.

STUDY DESIGN: Retrospective. OBJECTIVE: With approximately 10,000 new spinal cord injury (SCI) patients in the United States each year, predicting public health outcomes is an important public health concern. Combining all regions of the spine in SCI trials may be misleading if the lumbar and sacral regions (conus) have a neurologic improvement at different rates than the thoracic or thoracolumbar spinal cord. SUMMARY OF BACKGROUND DATA: Over a 10-year period between January 1995 to 2005, 1746 consecutive spinal injured patients were seen, evaluated, and treated through a level 1 trauma referral center. A retrospective analysis was performed on 150 patients meeting the criteria of T4 to S5 injury, excluding gunshot wounds. One-year follow-up data were available on 95 of these patients. METHODS: Contingency table analyses (chi-squared statistics) and multivariate logistic regression. Variables of interest included level of injury, initial American Spinal Injury Association (ASIA), age, race, and etiology. RESULTS: A total of 92.9% of lumbar (conus) patients neurologically improved one ASIA level or more compared with 22.4% of thoracic or thoracolumbar spinal cord-injured patients. Only 7.7% of ASIA A patients showed neurologic improvement, compared with 95.2% of ASIA D patients; ASIA B patients demonstrated a 66.7% improvement rate, whereas ASIA C had a 84.6% improvement rate. When the two effects were considered jointly in a multivariate analysis, ASIA A and thoracic/thoracolumbar patients had only a 4.1% rate of improvement, compared with 96% for lumbar (conus) and incomplete patients (ASIA B-D) and 66.7% to 72.2% for the rest of the patients. All of these relationships were significant to P < 0.001 (chi-square test). There was no link to age or gender, and race and etiology were secondary to region and severity of injury. CONCLUSION: Thoracic (T4-T9) SCIs have the least potential for neurologic improvement. Thoracolumbar (T10-T12) and lumbar (conus) spinal cord have a greater neurologic improvement rate, which might be related to a greater proportion of lower motor neurons. Thus, defining the exact region of injury and potential for neurologic improvement should be considered in future clinical trial design. Combining all anatomic regions of the spine in SCI trials may be misleading if different regions have neurologic improvement at different rates. Over a ten-year period, 95 complete thoracic/thoracolumbar SCI patients had only a 4.1% rate of neurologic improvement, compared with 96.0% for incomplete lumbar (conus) patients and 66.7% to 72.2% for all others.