Etiology and Outcomes of Spinal Cord Infarct: A Case Series From a Level 1 Trauma Center.

STUDY DESIGN: Retrospective study. OBJECTIVES: To evaluate the demographics, prevalence, etiology, severity, and outcomes of spinal cord injuries (SCIs) resulting from ischemic infarction. METHODS: All patients with SCI and a diagnosis of cord infarct who were admitted to the inpatient rehabilitation unit at a level 1 trauma center from January 2003 to January 2014 were identified using an administrative billing database. Outcomes measures were evaluated. RESULTS: Among 685 unique SCI patients who were identified, 30 (4.4%) had SCI due to spinal ischemic infarction. The mean age was 59 years (range 17-80 years). Fifty percent of patients had ASIA (American Spinal Injury Association) A and B severity. Most common causes were the following: 6 (20%) abdominal aortic aneurysm (AAA) repairs, 6 (20%) arteriovenous fistulas, and 6 (20%) with an unknown cause. Surgical complications led to 4 (13.3%) cord infarcts and was associated with a higher severity of injury (P = .02) compared with other etiologies. Other causes included systemic hypotension, AAA rupture, trauma, diabetic ketoacidosis, and after radiation therapy. At follow-up, 6 (20%) of patients were able to ambulate normally without assistance, 7 (23.3%) were ambulating with assistance, and 17 (56.7%) were still wheelchair bound. Clinical improvement in ambulatory status was noted in 6 (20%) patients and was associated with less severe initial injury (P = .02). CONCLUSIONS: While the existing literature associates spinal cord infarction with aortic pathologies and surgery, these caused less than 30% of cases, while nonaortic surgical complications were associated with the most severe injuries. Outcomes were worse than previously reported in the literature.

Traumatic spinal cord injuries in geriatric population: etiology, management, and complications.

BACKGROUND: The relationship of traumatic spinal cord injury (SCI) and the geriatric population is not emphasized in current literature. Our objective was to evaluate mechanisms of injury, outcomes, and complications of geriatric patients with traumatic SCI. METHODS: Patients with traumatic spinal cord injuries admitted to the inpatient rehabilitation unit of a level I trauma center from 2003 to 2013 were reviewed. Inclusion criteria were ages ≥65 years old and availability of complete medical records. Patient demographics, mechanism of injury, diagnoses, American Spinal Injury Association (ASIA) grade, management (surgical, nonsurgical), complications, and mortality were evaluated. RESULTS: Seven hundred and fifty-seven SCI patients were identified and 53 met our inclusion criteria, with 35 (66.0%) males and 18 (34.0%) females. The average age was 74-years (range, 65 to 91 years). A proportion of 24.5% were 65-69 years of age, 30.2% were 70-74, 22.6% were 75-79, and 22.6% were 80 or older. Thirty-four (64.2%) underwent surgery. The two most common diagnoses of SCI were fractures (43.4%) and central cord syndrome (28.3%). ASIA grading was: A 5 (9.4%); B 3 (5.7%); C 5 (9.4%); D 40 (75.5%). The most severe SCI (ASIA score A and B) primarily occurred in the younger geriatric populations (ages 65-74), as did the highest rates of major complications or major and minor complications (15.4% and 46.2%, respectively, in the 65-69 group). Surgical management increased with age from 46.2% in the 65-69 group to 83.3% in the 75-79 group but subsequently decreased in the ≥80 group (66.7%). CONCLUSIONS: Fractures and central cord syndrome were the most common diagnoses and typically due to falls. The complication rate in this population is high and due to complex causes. SCI in patients aged 65-69 was associated with increased rate of ASIA score A and increased rate of major complications.

Spinal Cord Injury From Spinal Tumors: Prevalence, Management, and Outcomes.

BACKGROUND: With the aging population in the United States, it can be anticipated that the prevalence of spinal cord injuries (SCIs) and cancer will increase. Primary or metastatic spine tumors sit at a unique intersection of these 2 realms. Our objective was to evaluate the prevalence, outcomes, and complications after the management of SCI arising from spinal tumors. METHODS: In the present retrospective evaluation, all patients with SCI and a diagnosis of primary or metastatic spinal cancer who had been admitted to the inpatient rehabilitation unit at a level 1 trauma center from January 2003 to January 2014 were evaluated. The demographic data (age, sex, race/ethnicity), tumor characteristics, American Spinal Injury Association score, and complications were evaluated. RESULTS: A total of 757 SCI entries were identified, and 685 unique patients met our inclusion criteria. Of those, 81 had SCIs due to spinal tumors (11.8% of all SCIs and 19.2% of nontraumatic SCIs). Most tumors were located in the thoracic region (65.4%) and were primary central nervous system in origin (21.0%), including meningioma (7.4%), schwannoma (3.7%), and ependymoma (2.5%). The next most common origins of the spinal tumors were metastases from the lung (17.3%), prostate (9.9%), kidney (8.6%), lymphoma (7.4%), and multiple myeloma (7.4%). Of these patients, 76.5% underwent surgical management, with a complications rate of 61.3%. The overall mortality rate at the latest follow-up examination was 63.0%. CONCLUSIONS: SCI associated with spinal tumor is often managed surgically and associated with high rates of complications. The present study has demonstrated longer survival rates compared with the existing data.

T cell developmental arrest in former premature infants increases risk of respiratory morbidity later in infancy.

The inverse relationship between gestational age at birth and postviral respiratory morbidity suggests that infants born preterm (PT) may miss a critical developmental window of T cell maturation. Despite a continued increase in younger PT survivors with respiratory complications, we have limited understanding of normal human fetal T cell maturation, how ex utero development in premature infants may interrupt normal T cell development, and whether T cell development has an effect on infant outcomes. In our longitudinal cohort of 157 infants born between 23 and 42 weeks of gestation, we identified differences in T cells present at birth that were dependent on gestational age and differences in postnatal T cell development that predicted respiratory outcome at 1 year of age. We show that naive CD4+ T cells shift from a CD31-TNF-α+ bias in mid gestation to a CD31+IL-8+ predominance by term gestation. Former PT infants discharged with CD31+IL8+CD4+ T cells below a range similar to that of full-term born infants were at an over 3.5-fold higher risk for respiratory complications after NICU discharge. This study is the first to our knowledge to identify a pattern of normal functional T cell development in later gestation and to associate abnormal T cell development with health outcomes in infants.

Traumatic and Nontraumatic Spinal Cord Injuries.

OBJECTIVE: Owing to the aging of the population in the United States, it is anticipated that injury mechanisms, treatment, and outcomes of spinal cord injuries (SCI) will change. There is a scarcity of literature on nontraumatic SCI. Our goal in this study was to evaluate the causes, management, complications, and outcomes after SCI. METHODS: In a retrospective review, patients with traumatic and nontraumatic SCI admitted to the inpatient rehabilitation unit at a level 1 trauma center from 2003 to 2013 were reviewed. RESULTS: In all, 757 entries were identified, and 685 unique patients met our inclusion criteria; 17.4% were <35 years of age, 51.7% were 35 to 64 years of age, and 30.9% were at least 65 years old. The young adults had the highest proportion of fractures (60.5%) and subluxations (21.8%), whereas the oldest group had the highest rates of stenosis (35.4%), spondylotic myelopathy (16.5%), and cancer (15.1%). In SCI patients <35 years of age, 66.6% of injuries were caused by traumatic mechanisms of injury compared with 30.2% in the geriatric cohort. In the total of all SCI, 61.6% were nontraumatic. Surgical management was more prevalent with increasing age (58.8%, 73.7%, 82.1% from youngest to oldest group), as were overall rates of complications (58.6%, 59.4%, 66.7%). Mortality rates significantly increased with age (2.5%, 18.9%, 40.6% overall mortality rates in the 3 age groups). The overall mortality rate in nontraumatic SCI patients was 27.7% compared with 14.8% in traumatic SCI patients. CONCLUSIONS: Falls caused significantly more SCIs than expected, but most SCIs were predominantly nontraumatic in cause. The epidemiology of SCI is shifting rapidly.

The Top 100 Cited Papers in Health Care Disparities: a Bibliometric Analysis.

Health care disparities research is an exponentially growing and multi-faceted field. Our objective was to identify and analyze the top 100 cited articles in health care disparities. The authors searched the Thomas Reuters Web of Science for citations of all research papers (articles) relevant to health care disparities. After analyzing search results, the number of citations, authorship, year, journal, country of publication, institution of publication, and relevant topic were recorded for each article. The most cited article was Martin's 2002 work identifying the demography of incidence and occurrence of sepsis with specific analysis of race, sex, and disposition of US patients. The second most cited article was Kamangar's 2006 paper outlining geographic patterns in cancer incidence, mortality, and prevalence. The third most cited article was Williams' 1996 study determining the differences in US health patterns in populations of different races and socioeconomic statuses through a review of similar studies. The majority of articles originated in the USA (91). The journal with the most published articles was JAMA-The Journal of the American Medical Association (14). The second most cited journal was The New England Journal of Medicine (7). Most articles were published in the 2000s (84). In descending order, the 3 most common topics were (1) disparities in cancer incidence, screening, treatment, and mortality, (2) disparities in mental health treatment, and (3) physician concordance, cultural competency, and relationships with minority patients. Overall, the highly cited articles contain current advancements in the body of knowledge used to resolve health care disparities in race, ethnicity, socioeconomic status, gender, age, wealth, education level, mental health, and geography throughout the world.