The Association Between Tranexamic Acid and Seizures in Moderate or Severe Traumatic Brain Injury.

INTRODUCTION: Tranexamic acid (TXA) administered within 2 h of injury reduces mortality in traumatic brain injury (TBI) with intracranial hemorrhage. TXA also reduces the seizure threshold in a dose-dependent manner. We examined whether a 2-g bolus of prehospital TXA administered in moderate or severe TBI is associated with seizure activity within 72 h of injury. METHODS: Patients from the prehospital TXA for TBI trial with Glasgow Coma Scale < 13, blunt head injury, and time-of-seizure data were included in this analysis. The original trial randomized patients with suspected TBI to placebo, 1-g TXA bolus + 1-g 8-h TXA infusion, or 2-g TXA bolus within 2 h of injury. In this secondary analysis, multivariable logistic regression was performed to examine the association of treatment group with seizure incidence. The model controlled for age, Glasgow Coma Scale, Injury Severity Score, intracranial hemorrhage, Abbreviated Injury Scale-head, and home antiseizure medication use. RESULTS: Of the 786 patients who met the inclusion criteria, 19 had seizures within 72 h (five in placebo, two in 1-g bolus/1-g infusion, and 12 in 2-g bolus). The 2-g TXA bolus was not associated with increased seizures compared to placebo (odds ratio 0.41, 95% confidence interval 0.12-1.18, P = 0.12). Home antiseizure medication use was associated with increased seizures (odds ratio 15.95, 95% confidence interval 3.79-60.57, P < 0.001). CONCLUSIONS: A prehospital 2-g TXA bolus in moderate or severe TBI was not associated with increased seizure activity during the first 72 h after injury; however, limited power, limited use of continuous electroencephalography, and unavailable seizure prophylaxis data highlight the need for further study.

The effects of prehospital TXA on mortality and neurologic outcomes in patients with traumatic intracranial hemorrhage: a subgroup analysis from the prehospital TXA for TBI trial.

BACKGROUND: In the Prehospital Tranexamic Acid (TXA) for TBI Trial, TXA administered within two hours of injury in the out-of-hospital setting did not reduce mortality in all patients with moderate/severe traumatic brain injury (TBI). We examined the association between TXA dosing arms, neurologic outcome, and mortality in patients with intracranial hemorrhage (ICH) on computed tomography (CT). METHODS: This was a secondary analysis of the Prehospital Tranexamic Acid for TBI Trial (ClinicalTrials.gov [NCT01990768]) that randomized adults with moderate/severe TBI (Glasgow Coma Scale<13) and systolic blood pressure > =90 mmHg within two hours of injury to a 2-gram out-of-hospital TXA bolus followed by an in-hospital saline infusion, a 1-gram out-of-hospital TXA bolus/1-gram in-hospital TXA infusion, or an out-of-hospital saline bolus/in-hospital saline infusion (placebo). This analysis included the subgroup with ICH on initial CT. Primary outcomes included 28-day mortality, 6-month Glasgow Outcome Scale-Extended (GOSE) < = 4, and 6-month Disability Rating Scale (DRS). Outcomes were modeled using linear regression with robust standard errors. RESULTS: The primary trial included 966 patients. Among 541 participants with ICH, 28-day mortality was lower in the 2-gram TXA bolus group (17%) compared to the other two groups (1-gram bolus/1-gram infusion 26%, placebo 27%). The estimated adjusted difference between the 2-gram bolus and placebo groups was -8·5 percentage points (95% CI, -15.9 to -1.0) and between the 2-gram bolus and 1-gram bolus/1-gram infusion groups was -10.2 percentage points (95% CI, -17.6 to -2.9). DRS at 6 months was lower in the 2-gram TXA bolus group than the 1-gram bolus/1-gram infusion (estimated difference -2.1 [95% CI, -4.2 to -0.02]) and placebo groups (-2.2 [95% CI, -4.3, -0.2]). Six-month GOSE did not differ among groups. CONCLUSIONS: A 2-gram out-of-hospital TXA bolus in patients with moderate/severe TBI and ICH resulted in lower 28-day mortality and lower 6-month DRS than placebo and standard TXA dosing. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level II.

Diagnostic criteria of traumatic central cord syndrome. Part 2: a questionnaire survey among spine specialists.

STUDY DESIGN: A questionnaire survey. OBJECTIVES: To evaluate the need for the introduction of quantitative diagnostic criteria for the traumatic central cord syndrome (TCCS). SETTING: An online questionnaire survey with participants from all over the world. METHODS: An invitation to participate in an eight-item online survey questionnaire was sent to surgeon members of AOSpine International. RESULTS: Out of 3340 invited professionals, 157 surgeons (5%) from 41 countries completed the survey. Whereas most of the respondents (75%) described greater impairment of the upper extremities than of the lower extremities in their own TCCS definitions, symptoms such as sensory deficit (39%) and bladder dysfunctions (24%) were reported less frequently. Initially, any difference in motor strength between the upper and lower extremities was considered most frequently (23%) as a 'disproportionate' difference in power. However, after presenting literature review findings, the majority of surgeons (61%) considered a proposed difference of at least 10 points of power (based on the Medical Research Council scale) in favor of the lower extremities as an acceptable cutoff criterion for a diagnosis of TCCS. Most of the participants (40%) felt that applying a single criterion to the diagnosis of TCCS is insufficient for research purposes. CONCLUSION: Various definitions of TCCS were used by physicians involved in the spinal trauma care. The authors consider a difference of at least 10 motor score points between upper and lower extremity power a clear diagnostic criterion. For clinical research purposes, this diagnostic criterion can be considered as a face valid addendum to the commonly applied TCCS definition as introduced by Schneider et al.

Tranexamic Acid, Mortality, and Intracranial Hemorrhage Type in Moderate or Severe Traumatic Brain Injury.

This cohort study examines the association of tranexamic acid administration with intracranial hemorrhage type, neurologic outcomes, and mortality in patients with traumatic brain injury.

Luteinizing hormone-releasing hormone. Antiovulatory activity of analogs substituted in positions 2 and 6.

Ten analogs of luteinizing hormone-releasing hormone (LH-RH) substituted in position 2 with D-amino acids and at 6 with either a D-amino acid or a nonasymmetric amino acid were synthesized by solid-phase methodology and assayed for antiovulatory activity. [D-Phe2]-LH-RH substituted in the 6 position with D-Ala, D-Leu, D-Arg, D-(Ph)Gly, D-Phe, or 2-Me-Ala possessed varying degrees of antiovulatory activity. [D-p-F-Phe2-D-Ala6]-LH-RH was one of the most active antiovulatory compounds, while the [D-p-Cl-Phe2-D-Ala6]-LH-RH analog was devoid of activity at a comparable dose.

Postcoital contraceptive effects of agonist analogs of luteinizing hormone-releasing hormone.

Various analogs of synthetic hypothalamic luteinizing hormone-releasing hormone (LH-RH) were evaluated for agonistic (ovulation-inducing), postcoital contraceptive, and direct uterotrophic activities. All analogs showing agonistic activity also possessed the ability to terminate pregnancy, as did LH-RH; there appeared to be a direct relationship between agonistic and postcoital potency and activity. The highly potent and active LH-RH agonist, D-[Ala]6-des-[Gly]10-pro9-ethylamide-LH-RH, proved to be the most potent and active postcoital preimplantational and postimplantational antifertility agent. In contrast to LH-RH, none of the analogs tested in the hypophysectomized animal produced a uterotrophic effect, revealing a selective extrapituitary effect of the parent hormone. The collective data demonstrate that peptides derived from LH-RH and bearing agonistic properties can terminate pregnancy postcoitally, via disruption of the pituitary-ovarian reproductive complex. Possible mechanisms are discussed, and the use of members of this neurohormonal class as potential profertility agents should be weighed with caution.

Charcot shoulder joint associated with syringomyelia: a case report.

A 36-year-old man with degenerative disease of the spine and cervical syringomyelia (syrinx) presented with new weakness and numbness in his left upper extremity. Examination revealed decreased range of motion (ROM), swelling, weakness, and diminished pinprick, vibratory, and proprioceptive sensation in the left upper extremity. Radiographic examination showed a severe destructive arthropathy; a biopsy ruled out malignancy. A culture was negative for infection, and a repeat magnetic resonance imaging (MRI) showed a patent syringo-peritoneal shunt with no change in syrinx size. He was diagnosed with a Charcot shoulder. Treatment consisted of nonsteroidal anti-inflammatory medication, passive motion exercises, and a protective sling. The patient with syringomyelia may experience sensory loss that prevents normal guarding, resulting in repetitive trauma and eventual joint destruction. Appropriate assessment, diagnostic work-up, and treatment are essential in the management of the Charcot joint. Patient education, including information on activities that may be harmful, must be included, as such knowledge may slow or prevent the impairment that comes with a Charcot joint.

Comparison of rehabilitation outcomes in violent versus non-violent traumatic SCI.

This paper represents the results of a cohort study comparing functional outcomes of individuals with violent and non-violent traumatic spinal cord injury (SCI) following inpatient rehabilitation. Twenty-seven consecutive patients with a diagnosis of traumatic SCI of violent etiology (gunshot wound, stabbing or assault) and 27 patients with non-violent etiology (motor vehicle accident and falls) were matched for neurological level of injury and classification. Demographic comparison of violent versus non-violent groups revealed mean age 30 versus 39, gender 93 percent versus 78 percent male, race 89 percent versus 59 percent non-white, 74 percent versus 41 percent unmarried and 56 percent versus 22 percent unemployed, respectively. Violent and non-violent traumatic SCI groups had similar lengths of stay, admission and discharge functional independent measures (FIM), FIM improvement, payor sources, hospital charges and discharge to home rates. Despite the differences noted in the demographics of violent and non-violent traumatic SCI, these two matched groups achieved similar functional outcomes and discharge disposition following inpatient rehabilitation.

Age-related differences in length of stays, hospitalization costs, and outcomes for an injury-matched sample of adults with paraplegia.

OBJECTIVE: To investigate the effects of age at injury on neurological and functional outcomes and hospitalization length of stays and charges following spinal cord injuries resulting in paraplegia. METHODS: Subjects were 180 adults with paraplegia who were assessed in acute care and inpatient rehabilitation as part of the National Institute on Disability and Rehabilitation Research Model Spinal Cord Injury Systems. Age differences were examined by separating the sample into 3 age groups (18-39, 40-59, and 60+ years). A matched block design was used to control for injury characteristics. Cramer's statistic was used to identify age-related differences in qualitative variables; 3 x 5 one-way analysis of variance identified the main effects of age on quantitative variables. Tukey post hoc tests were performed to identify differences between age and age x injury characteristic variable levels. OUTCOME AND TREATMENT MEASURES: American Spinal Injury Association motor index scores, Functional Independence Measure (FIM) motor scores, discharge to private residence ratios, and hospitalization length of stays and charges were outcome and treatment measures. RESULTS: Age-related differences were found for etiology and health care plan, as well as for preinjury marital status, education level, and employment status. The main effects of age at injury were found for the following treatment and outcome measures: rehabilitation length of stays, FIM motor scores at rehabilitation discharge, FIM motor improvement (change), and FIM motor daily improvement (efficiency). Tukey post hoc tests revealed that older patients had longer rehabilitation stays, lower rehabilitation discharge FIM motor scores, and showed less improvement compared with younger and middle-aged injury-matched patients. No age-related differences were found in rates of discharge disposition. CONCLUSIONS: Using a matched block design procedure, older patients are discharged with lower levels of functional independence and show lower levels of improvement despite longer rehabilitation stays when compared with younger patients. Older patients' neurological recovery appears equivocal to younger patients' recovery. In contrast to findings with a matched tetraplegia sample, older and younger patients with paraplegia are discharged to private residences at similar rates.

Rehabilitation outcome of individuals with nontraumatic myelopathy resulting from spinal stenosis.

A study was undertaken of 46 patients (19 cervical and 27 lumbar) admitted to an inpatient rehabilitation unit following surgical decompression for myelopathy or cauda equina syndrome resulting from spinal stenosis (SS). Individuals with SS represented 16 percent of all spinal cord injury (SCI) admissions. When compared to patients with traumatic SCI, patients with SS were significantly (t-test, p < .01) older (mean age 68 versus 39 years), more frequently retired/unemployed (89 percent versus 43 percent), more often married (57 percent versus 36 percent) and less often male (54 percent versus 82 percent) but with similar ethnicity. Significant (p < .01) Functional Independence Measurement (FIM) changes for the SS patients were noted after rehabilitation in the categories of self-care, sphincter control and mobility/locomotion. Additionally, outcome comparisons with a group of traumatic SCI patients who had similar motor function revealed similar lengths of stay, discharge FIM scores and discharge-to-community rates. This study suggests that individuals with weakness secondary to SS represent a significant proportion of individuals with SCI, make significant functional gains following inpatient rehabilitation and can achieve functional outcomes similar to those of traumatic SCI individuals.

Determining impairment following spinal cord injury.

Determining the level of impairment and disability of an individual with SCI is reasonably straightforward. An impairment rating may be determined by either analyzing the impact of the SCI on various bodily systems or by considering the injury as a more global diagnostic category. Functional abilities based on level of neurologic preservation are well recognized. Although secondary medical complications, which may affect both impairment and disability, can arise at any time after SCI, neurologic and functional abilities are overwhelmingly stabilized by 12 months postinjury. A comprehensive history and physical examination should allow even the inexperienced examiner to obtain a valid determination of impairment after SCI. Although a more functionally oriented and perhaps interdisciplinary evaluation is needed to assess disability, it is also fairly straightforward. On the other hand, an evaluation of handicap is a more challenging undertaking, requiring a more detailed knowledge of the field of vocational rehabilitation.

Late return of diaphragm function in a ventilator-dependent patient with a high cervical tetraplegia: case report, and interactive review.

Return of diaphragm function in an individual with ventilator-dependent high cervical tetraplegia is presented. The patient was maintained on a ventilator for five years after sustaining a C3-C4 vertebral fracture with a complete high cervical tetraplegia. Diaphragmatic fluoroscopic evaluation at the initial injury time revealed a nonfunctioning diaphragm, and the patient was subsequently discharged home on a portable ventilator. Respiratory evaluation 5 years post injury, including, diaphragmatic fluoroscopy, transcutaneous phrenic nerve conduction studies and pulmonary function tests, revealed intact phrenic nerve function bilaterally with spontaneous diaphragmatic motion. Subsequently, successful ventilatory weaning and diaphragmatic muscle strengthening was achieved. This case report emphasises the importance of serial evaluation of phrenic nerve viability, diaphragmatic function and ventilator dependency in patients with a high cervical tetraplegia in light of potential neurological recovery.

Optical system defect propagation in ABCD systems.

We describe how optical system defects (tilt/jitter, decenter, and despace) propagate through an arbitrary paraxial optical system that can be described by an ABCD ray transfer matrix. A pedagogical example is given that demonstrates the effect of alignment errors on a typical optical system.

Neoplastic vs. traumatic spinal cord injury: an inpatient rehabilitation comparison.

OBJECTIVE: To compare demographics, injury characteristics, and functional outcomes of patients with neoplastic spinal cord compression with those with traumatic spinal cord injuries. DESIGN: A prospective 5-yr comparison was undertaken comparing 34 patients with neoplastic spinal cord compression with 159 patients with traumatic spinal cord injury. RESULTS: Patients with neoplastic spinal cord compression were significantly older, more often female, and unemployed than patients with traumatic spinal cord injury. Neoplastic spinal cord compression presented more often with paraplegia involving the thoracic spine, and injuries were more often incomplete compared with traumatic spinal cord injury. Patients with neoplastic spinal cord compression had a significantly shorter rehabilitation length of stay compared with those with traumatic spinal cord injury. The neoplastic group had significantly lower FIM change scores. Both groups had similar FIM efficiencies and discharge to home rates. CONCLUSIONS: Patients with neoplastic spinal cord compression have different demographic and injury characteristics but can achieve comparable rates of functional gains as their traumatic spinal cord injury counterparts. Although patients with traumatic injuries achieve greater functional improvement, patients with neoplasms have a shorter rehabilitation length of stay and comparable FIM efficiencies and home discharge rates.

Neoplastic versus traumatic spinal cord injury: an outcome comparison after inpatient rehabilitation.

OBJECTIVE: To compare outcomes of patients with neoplastic spinal cord compression (SCC) to outcomes of patients with traumatic spinal cord injury (SCI) after inpatient rehabilitation. DESIGN: A comparison between patients with a diagnosis of neoplastic SCC admitted to an SCI rehabilitation unit and patients with a diagnosis of traumatic SCI admitted to the regional Model Spinal Cord Injury Centers over a 5-year period, controlling for age, neurologic level of injury, and American Spinal Injury Association impairment classification. SETTING: Tertiary university medical centers. PATIENTS: Twenty-nine patients with neoplastic SCC and 29 patients with SCI of traumatic etiology who met standard rehabilitation admission criteria. MAIN OUTCOME MEASURES: Acute and rehabilitation hospital length of stay (LOS), Functional Independence Measure (FIM) scores, FIM change, FIM efficiency, and discharge rates to home. RESULTS: Patients with neoplastic SCC had a significantly (p < .01) shorter rehabilitation LOS than those with traumatic SCI (25.17 vs 57.46 days). No statistical significance was found in acute care LOS. Motor FIM scores on admission were higher in the neoplastic group, but discharge FIM scores and FIM change were significantly lower. Both groups had similar FIM efficiencies and community discharges. CONCLUSIONS: Patients with neoplastic SCC can achieve rates of functional gain comparable to those of their counterparts with traumatic SCI. While patients with traumatic SCI achieve greater functional improvement, patients with neoplastic SCC have a shorter rehabilitation LOS and can achieve comparable success with discharge to the community.

Substance abuse, violence, and outcome after traumatic spinal cord injury.

Alcohol and drug use have been shown to contribute to the onset of traumatic spinal cord injury and to be a marker for later onset substance abuse issues. Admission toxicology (drug and alcohol) screens were collected from 87 consecutive rehabilitation medicine patients with a diagnosis of acute traumatic spinal cord injury. Forty-six patients (53%) presented with positive screens (44% alcohol only, 30% drug only, 26% both). Seventy-five percent of those with positive alcohol screens met state criteria for alcohol intoxication (blood alcohol level, > or =0.08 mg/dl). Compared with individuals with negative screens, those with positive screens were significantly (P < 0.05) younger and unmarried. Compared with nonviolence-related spinal cord injury, patients with violence-related spinal cord injury (gunshot wound and assault) were significantly (P < 0.01) more likely to have positive admission toxicology screens (76% v 41%), drug screens (62% v 14%), and intoxication screens (72% v 34%). Rehabilitation outcome comparisons between those with positive and negative screens revealed similar length of stay, admission and discharge Functional Independence Measure (FIM) scores, FIM change scores, and FIM efficiency scores. This study has important implications with regard to substance abuse issues and their impact on traumatic spinal cord injury outcome, which may assist in better targeting prevention.

Clinical presentations, medical complications, and functional outcomes of individuals with gunshot wound-induced spinal cord injury.

Gunshot wounds are currently the second leading cause of spinal cord injury in the United States, and coexisting injuries or complications accompanying penetrating wounds often increase patient morbidity. A review of 217 traumatic spinal cord injury rehabilitation admissions to a tertiary care hospital during a 5-yr period revealed 49 individuals (23%) with gunshot wound-induced spinal cord injury. A single bullet entry site was seen in 54%, whereas 17% had greater than 3 sites of entry. Common (>25%) sites of bullet entry included the back, abdomen, neck, and chest. Common gunshot wound-related medical complications included pain (54%), infections (40%), pneumothorax (24%), nonspinal fractures (22%), colonic perforation (17%), cerebrospinal fluid leak (10%), and retroperitoneal hematoma (10%). When compared with nonviolence-related traumatic spinal cord injury (motor vehicle accidents and falls), patients with gunshot wound-induced spinal cord injury were significantly more frequently (P < 0.01) younger, non-Caucasian, unmarried, and unemployed. Injury characteristics revealed significantly (P < 0.01) more paraplegia and complete spinal cord injury within the gunshot wound-induced spinal cord injury group. Gunshot wound-induced spinal cord injury and nonviolent traumatic spinal cord injury groups had similar lengths of stay, Functional Independence Measure scores, and discharge to home rates. This article adds to the growing body of literature examining clinical, medical, and functional outcome characteristics of individuals with spinal cord injury secondary to violence-related cause.

Nontraumatic spinal cord injury: incidence, epidemiology, and functional outcome.

OBJECTIVES: To identify and compare the incidence, demographics, neurologic presentation, and functional outcome of individuals with nontraumatic spinal cord injury (SCI) to individuals with traumatic SCI. DESIGN: A 5-year prospective study. SETTING: Level I trauma center of a Regional SCI Model System. PATIENTS: Two hundred twenty adult SCI admissions. MAIN OUTCOME MEASURES: Demographics, etiology, level and completeness of injury, Functional Independent Measure (FIM) scores. RESULTS: Of SCI admissions, 39% were nontraumatic in etiology (spinal stenosis, 54%; tumor, 26%). Compared to subjects with traumatic SCI, those individuals with nontraumatic SCI were significantly (p < .01) older and were more likely married, female, and retired. Injury characteristics revealed significantly more paraplegia and incomplete SCI within the nontraumatic SCI group (p < .01). Both nontraumatic and traumatic SCI individuals had significant FIM changes from rehabilitation admission to discharge (p < .01). Those with tetraplegia-incomplete nontraumatic SCI had significantly higher admission motor FIM scores and shorter rehabilitation length of stay than in the traumatic group (p < .05). Paraplegic-complete and paraplegic-incomplete nontraumatic SCI subjects had lower discharge motor FIM scores, FIM change, and FIM efficiency than those with traumatic SCI. Similar discharge-to-home rates were noted in both nontraumatic and traumatic SCI groups. CONCLUSIONS: These data suggest that individuals with nontraumatic SCI represent a significant proportion of SCI rehabilitation admissions and, although differing from those with traumatic SCI in demographic and injury patterns, can achieve similar functional outcomes.