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Study design Predictive algorithm via decision treeObjectives Artificial intelligence (AI) remain an emerging field and have not previously been used to guide therapeutic decision making in thoracolumbar burst fractures. Building such models may reduce the variability in treatment recommendations. The goal of this study was to build a mathematical prediction rule based upon radiographic variables to guide treatment decisions.Methods Twenty-two surgeons from the AO Knowledge Forum Trauma reviewed 183 cases from the Spine TL A3/A4 prospective study (classification, degree of certainty of posterior ligamentous complex (PLC) injury, use of M1 modifier, degree of comminution, treatment recommendation). Reviewers’ regions were classified as Europe, North/South America and Asia. Classification and regression trees were used to create models that would predict the treatment recommendation based upon radiographic variables. We applied the decision tree model which accounts for the possibility of non-normal distributions of data. Cross-validation technique as used to validate the multivariable analyses.Results The accuracy of the model was excellent at 82.4%. Variables included in the algorithm were certainty of PLC injury (%), degree of comminution (%), the use of M1 modifier and geographical regions. The algorithm showed that if a patient has a certainty of PLC injury over 57.5%, then there is a 97.0% chance of receiving surgery. If certainty of PLC injury was low and comminution was above 37.5%, a patient had 74.2% chance of receiving surgery in Europe and Asia vs 22.7% chance in North/South America. Throughout the algorithm, the use of the M1 modifier increased the probability of receiving surgery by 21.4% on average.Conclusion This study presents a predictive analytic algorithm to guide decision-making in the treatment of thoracolumbar burst fractures without neurological deficits. PLC injury assessment over 57.5% was highly predictive of receiving surgery (97.0%). A high degree of comminution resulted in a higher chance of receiving surgery in Europe or Asia vs North/South America. Future studies could include clinical and other variables to enhance predictive ability or use machine learning for outcomes prediction in thoracolumbar burst fractures.

Study Design Retrospective analysis of prospectively collected data.Objectives To compare decision-making between an expert panel and real-world spine surgeons in thoracolumbar burst fractures (TLBFs) without neurological deficits and analyze which factors influence surgical decision-making.Methods This study is a sub-analysis of a prospective observational study in TL fractures. Twenty two experts were asked to review 183 CT scans and recommend treatment for each fracture. The expert recommendation was based on radiographic review.Results Overall agreement between the expert panel and real-world surgeons regarding surgery was 63.2%. In 36.8% of cases, the expert panel recommended surgery that was not performed in real-world scenarios. Conversely, in cases where the expert panel recommended non-surgical treatment, only 38.6% received non-surgical treatment, while 61.4% underwent surgery. A separate analysis of A3 and A4 fractures revealed that expert panel recommended surgery for 30% of A3 injuries and 68% of A4 injuries. However, 61% of patients with both A3 and A4 fractures received surgery in the real world. Multivariate analysis demonstrated that a 1% increase in certainty of PLC injury led to a 4% increase in surgery recommendation among the expert panel, while a .2% increase in the likelihood of receiving surgery in the real world.Conclusion Surgical decision-making varied between the expert panel and real-world treating surgeons. Differences appear to be less evident in A3/A4 burst fractures making this specific group of fractures a real challenge independent of the level of expertise.

Study design: Observational study. Objectives: To assess the construct validity of the International Standards to Document Remaining Autonomic Function after Spinal Cord Injury (ISAFSCI) (2012 1st Edition). Setting: Two Canadian spinal cord injury (SCI) centers. Methods: Data were collected between 2011–2014. Assessments included the ISAFSCI, standardized measures of autonomic function and a clinical examination. Construct validity of ISAFSCI was assessed by testing a priori hypotheses on expected ISAFSCI responses to standard measures (convergent hypotheses) and clinical variables (clinical hypotheses). Results: Forty-nine participants with an average age of 45 ± 12 years were included, of which 42 (85.7%) were males, 37 (77.6%) had a neurological level of injury at or above T6, and 23 (46.9%) were assessed as having motor and sensory complete SCI. For the six General Autonomic Function component hypotheses, two hypotheses (1 clinical, 1 convergent) related to autonomic control of blood pressure and one clinical hypothesis for temperature regulation were statistically significant. In terms of the Lower Urinary Tract, Bowel and Sexual Function component of the ISAFSCI, all the hypotheses (5 convergent, 3 clinical) were statistically significant except for the hypotheses on female sexual items (2 convergent, 2 clinical), likely due to small sample size. Conclusion: The construct validity of ISAFSCI (2012 1st Edition) for the General Autonomic Function component was considered to be weak while it was much stronger for the Lower Urinary Tract, Bowel and Sexual Function component based on a priori hypotheses. These results can inform future psychometric studies of the ISAFSCI (2021 2nd Edition).

Study design: Cross-sectional survey in Canada. Objectives: To explore multimorbidity (the coexistence of two/more health conditions) in persons with non-traumatic spinal cord injury (NTSCI) and evaluate its impact on healthcare utilization (HCU) and health outcomes. Setting: Community-dwelling persons. Methods: Data from the Spinal Cord Injury Community Survey (SCICS) was used. A multimorbidity index (MMI) consisting of 30 secondary health conditions (SHCs), the 7-item HCU questionnaire, the Short Form-12 (SF-12), Life Satisfaction-11 first question, and single-item Quality of Life (QoL) measure were administered. Additionally, participants were grouped as “felt needed healthcare was received” (Group 1, n= 322) or “felt needed healthcare was not received” (Group 2, n= 89) using the HCU question. Associations among these variables were assessed using multivariable analysis. Results: 408 of 412 (99%) participants with NTSCI reported multimorbidity. Constipation, spasticity, and fatigue were the most prevalent self-reported SHCs. Group 1 had a higher MMI score compared to Group 2 (p< 0.001). A higher MMI score correlated with the feeling of not receiving needed care (OR 1.4, 95% CI 1.08–1.21), lower SF-12 (physical/mental component summary scores), being unsatisfied with life, and lower QoL (all p< 0.001). Additionally, Group 1 had more females (p< 0.001), non-Caucasians (p= 0.034), and lower personal annual income (p= 0.025). Conclusions: Persons with NTSCI have multimorbidity, and the MMI score was associated with increased HCU and worse health outcomes. This work emphasizes the critical need for improved healthcare and monitoring. Future work determining specific thresholds for the MMI could be helpful for triage screening to identify persons at higher risk of poor outcomes.

Study design: Cohort study. Objectives: It is widely accepted that the prediction of long-term neurologic outcome after traumatic spinal cord injury (SCI) can be done more accurately with neurological examinations conducted days to weeks post injury. However, modern clinical trials of neuroprotective interventions often require patients be examined and enrolled within hours. Our objective was to determine whether variability in timing of neurological examinations within 48 h after SCI is associated with differences in observations of follow-up neurologic recovery. Setting: Level I trauma hospital. Methods: An observational analysis testing for differences in AIS conversion rates and changes in total motor scores by neurological examination timing, controlling for potential confounders with multivariate stepwise regression. Results: We included 85 patients, whose mean times from injury to baseline and follow-up examinations were 11.8 h (SD 9.8) and 208.2 days (SD 75.2), respectively. AIS conversion by 1+ grade was significantly more likely in patients examined at ≤4 h in comparison with later examination (78% versus 47%, RR = 1.66, p= 0.04), even after controlling for timing of surgery, age, and sex (OR 5.0, 95% CI 1.1–10, p= 0.04). We failed to identify any statistically significant associations for total motor score recovery in unadjusted or adjusted analyses. Conclusions: AIS grade conversion was significantly more likely in those examined ≤4 h of injury; the effect of timing on motor scores remains uncertain. Variability in neurological examination timing within hours after acute traumatic SCI may influence observations of long-term neurological recovery, which could introduce bias or lead to errors in interpretation of studies of therapeutic interventions.

AbstractBackgroundSurvival estimates are integral to care for patients diagnosed with dementia. Few Canadian studies have carried out long-term follow-up of well-described cohorts, analyzing survival related to multiple risk factors. MethodsSurvival analysis of an inception cohort enrolled at a British Columbia (BC) tertiary dementia referral clinic between 1997 and 1999 was undertaken. Vital status was completed for 168 patients diagnosed with dementia. An evaluation of the effects of demographics, vascular risk factors, cognitive and functional ratings, apolipoprotein 4-status, and cholinesterase use on survival was performed using a log-rank test and time-dependent Cox regression. Survival of this dementia cohort was compared with the age-matched life expectancy of persons in BC. ResultsIn all, 158/168 (94.0%) subjects died over 16.6 years, with a median survival of 7.08 years. Risk factors associated with shorter survival in dementia groups included age of onset ≥80 (hazard ratio [HR] 1.56, 95% confidence interval [CI] 1.05-2.32); greater functional disability (Disability Assessment for Dementia<55% [HR 1.47, 95% CI 1.04-2.08]); and cumulative medical illness severity (Cumulative Illness Rating Scale≥7 [HR 1.51, 95% CI 1.08-2.12)]. Compared with the BC population, years of potential life lost for dementia subjects aged <65 was 15.36 years, and for dementia subjects aged ≥80 it was 1.82 years. ConclusionsSurvival in dementia subjects is shorter than population life expectancies for each age strata, with greatest impact on younger patients. For people diagnosed with dementia, age ≥80 years, cumulative medical illness severity, and functional disabilities are the most significant survival predictors and can be used to guide prognosis.

Objective. The disruption of autonomic function following a spinal cord injury (SCI) is common and can negatively affect quality of life. The objective of this study was to describe the prevalence of bladder/bowel incontinence and sexual dysfunction in community-dwelling individuals with a thoracolumbar SCI and examine the impact on general physical and mental health status.Methods. Participants who sustained a traumatic SCI to the thoracolumbar region of the spinal cord and classified as American Spinal Injury Association Impairment Scale (AIS) A to D were recruited. Demographic, injury data, MRI classification and neurological data were collected on admission. At follow-up, the neurological data, a questionnaire collecting participant-reported secondary health conditions (SHCs) (e.g. bladder incontinence, depression etc.) following SCI and health status measured by Short Form-36 were obtained. Regression models determined the association of health status with demographic/injury-related data, types and number of SHCs.Results. Of the 51 participants, 58.8% reported bladder incontinence, 54.0% bowel incontinence, 60.8% sexual dysfunction and 29.4% had all three. The regression models demonstrated that age at injury, bowel incontinence, sexual dysfunction, presence of pain, motor score at follow-up and the number of SHCs were significant predictors of health status. The number of SHCs was more predictive than all other demographic and injury variables for health status.Conclusion. Results highlight the high prevalence of self-reported bowel/bladder incontinence and sexual dysfunction in the traumatic thoracolumbar SCI population and support the need for standardized assessments. Several demographic, injury-related and SHCs impacted health status and should be considered for the management of individuals living in the community.

The authors used OCT-based volumetric assessment to determine factors that predict response of pigment epithelial detachments in neovascular age-related macular degeneration to treatment with intravitreal bevacizumab. Predominantly serous pigment epithelial detachments responded more favorably. Also, the initial response to the first treatment was predictive of the overall final response to treatment.

The authors used optical coherence tomography to measure choroidal thickness and the rate of choroidal thinning in patients with birdshot chorioretinopathy. Patients with birdshot chorioretinopathy were found to have thinner choroid and an increased rate of choroidal thinning compared with normal controls, despite having clinically inactive uveitis.

Written corrective feedback (henceforth CF) has been an issue of substantial controversies and debates. Although the focus of current CF studies has primarily been on grounding the value of focused CF, evidence on the benefits of unfocused CF is still limited. Moreover, it is essential to explore whether and how correction impacts the complexity of students’ writings to diminish the prospect that CF accuracy improvement is actually caused by evading more complex language use. The current study examined the effectiveness of unfocused written CF on the syntactic and lexical complexity of students’ writing. The participants were 30 homogeneous advanced learners from an English Institute located in Yazd; they were divided into experimental and control groups. Both groups were asked to write 10 compositions during the course but only the experimental group received unfocused CF for each essay. A computerized text analysis (Analyzer) was used to measure the linguistic properties of the written compositions. Syntactic complexity (ratio of subordination and average sentence length of the written texts) and lexical complexity (lexical diversity and lexical density) were calculated by the program. Using Multivariate analysis revealed a significant gain for both syntactic and lexical complexity in the experimental group. The paper concluded with theoretical and pedagogical implications of unfocused written CF for future research and classroom use.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Introduction Previous meta-analyses of methylprednisolone for patients with acute traumatic spinal cord injuries (TSCIs) have not addressed confidence in pooled effect estimates and new primary studies have been recently published. We performed a systematic review and meta-analysis to determine whether methylprednisolone improves motor recovery and is associated with increased risks for adverse events.Material and Methods We searched MEDLINE, EMBASE, and The Cochrane Library for eligible randomized controlled trials (RCTs) and controlled observational studies. Two reviewers independently screened articles, extracted data, and evaluated risk of bias. We pooled outcomes from RCTs and controlled observational studies separately using random effects models. We quantified heterogeneity using the chi-squared test and the I-squared statistic, and we pre-specified subgroup hypotheses to explain potential high heterogeneity. We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach to evaluate confidence.Results We included four RCTs and 17 observational studies. Methylprednisolone did not increase long-term motor score recovery (two RCTs: 335 participants, mean difference [MD] -1.11, 95% CI -4.75 to 2.53, p= 0.55, low certainty; two observational studies: 528 participants, MD 1.37, 95% CI -3.08 to 5.83, p= 0.55, very low certainty) or improvement by at least one motor grade (three observational studies: 383 participants, risk ratio [RR] 0.84, 95% CI 0.53 to 1.33, p= 0.46, very low certainty). Evidence from two RCTs demonstrated superior short-term motor score improvement if methylprednisolone was administered within eight hours of injury (two RCTs: 250 participants; MD 4.46, 95% CI 0.97 to 7.94, p= 0.01; low certainty), but risk of bias and imprecision limit confidence in these findings. Observational studies demonstrated a significantly increased risk for gastrointestinal bleeding (eight studies: 2727 participants, RR 2.53; 95% CI 1.48 to 4.32; p< 0.01, very low certainty), but RCTs did not. Risks for other adverse events were not significantly increased.Conclusion Methylprednisolone does not provide significant long-term benefit to patients with acute TSCIs and may be associated with increased gastrointestinal bleeding. These findings support current guidelines against routine use, but strong recommendations are not warranted because confidence in the effect estimates is limited. This meta-analysis advances current understanding because it includes recent studies not pooled previously and it is the first to consider confidence in the pooled effect estimates. Further research could increase confidence and clarify the influence of potential confounders or effect modifiers.