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OBJECTIVE To determine the impact of smoking on intensive care unit (ICU) outcomes in patients who underwent operative fixation for spine trauma. DESIGN Retrospective cohort study. SETTING Single academic level I trauma center. PATIENTS One hundred eighty-one consecutive surgical spine trauma patients from January 2010 to December 2014 requiring ICU stay. INTERVENTION Patients with smoking history compared to patients with no previous smoking history. MAIN OUTCOME MEASUREMENTS ICU length of stay, postoperative complications. RESULTS There were 297 spine trauma patients identified, of which 181 had an ICU stay (61%). There were 96 patients in the smoker cohort (53%) and 85 in the nonsmoker cohort (47%). On univariate analysis, the smoking cohort had a significantly longer ICU length of stay (11.0 ± 12.0 days vs. 8.01 ± 7.98 days, P = 0.046). Adjusting for confounders, smoking (beta: 3.99, P = 0.023), age ≥65 years (beta: 7.61, P = 0.001), body mass index ≥30 (beta: 4.47, P = 0.010), and American Spinal Injury Association Impairment Scale (beta: -1.39, P = 0.013) were independently associated with increased ICU length of stay. Smoking was not significantly associated with pneumonia (P = 0.238) or adult respiratory distress syndrome (P = 0.387) on multivariate analysis. CONCLUSIONS A history of smoking, older age, obesity, and increasing American Spinal Injury Association Impairment Scale was independently associated with increased ICU length of stay in patients with surgical spine trauma. This study highlights the health care burden of smoking in the trauma population and may help physicians triage scarce ICU resources. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patients with chronic pancreatitis (CP) are at increased risk of low bone mineral density (BMD), although the prevalence of low BMD in patients with CP in the United States is lacking. We aimed to determine the prevalence of low BMD and identify potential risk factors, including hypogonadism and use of opioid medications, in subjects with CP in the United States.This was a prospective, observational study. Subjects with CP underwent dual-energy x-ray absorptiometry scan. Blood was assayed for vitamin D, sex hormones, and a metabolic panel. History was obtained for fractures, menopause, hypogonadal symptoms, and opioid medication doses. Low BMD was defined by both World Health Organization and the International Society for Clinical Densitometry criteria.Depending on criteria used, 37% to 55% of our cohort had low BMD. Subjects with low and normal BMD had similar vitamin D levels. Hypogonadism was present in 27% of nonmenopausal subjects and was associated with reduced lumbar spine BMD in subjects 30 years or older.Patients with CP are at increased risk of low BMD, which is likely multifactorial. Hypogonadism, possibly related to opioid pain medications, may be an independent risk factor for low BMD in CP.

Retrospective.The purpose of this project is to identify factors that predict vertebral artery injury (VAI) in an effort to assess risks and benefits of computed tomography angiography (CT-A) of the neck in the trauma setting. We seek to develop guidelines for practitioners to stratify patients at medium/high risk of VAI from those who are at low risk.VAI and blunt carotid injury (BCI) together comprise blunt cerebrovascular injury (BCVI). More is known about risk factors for BCI than for VAI, but the neurovascular complications associated with VAI are similarly disastrous. With increasing frequency, trauma providers are using CT-A to screen for BCVI; this test carries risks that include radiation exposure and nephrotoxicity, in addition to higher cost of treatment and longer hospital stay.Trauma patients seen over 4 months at an urban, level 1 trauma were analyzed. BCVI screening was conducted in 144/1854 (7.77%) patients. Presence of VAI and several clinical characteristics were recorded. Univariate analysis and binomial logistic regression analysis were conducted at a 95% significance level.VAI was diagnosed in 0.49% of the study population. Univariate analysis determined six factors associated with positive VAI screening. Regression analysis showed four factors that independently predicted VAI: female sex, decreased Glasgow Coma Scale, cervical spine (c-spine) fracture, and concurrent BCI. A positive c-spine physical examination trended toward predicting VAI without achieving significance.Several independent predictors of VAI were identified. This study highlights the importance of identifying patients at a higher risk for VAI and indicating CT-A of the neck versus those who are at low risk and can be evaluated without undergoing advanced imaging, as CT-A appears unnecessary for most trauma patients.3.

SUMMARY: The objective of NRG Oncology RTOG 0123 was to test the ability of the angiotensin converting enzyme inhibitor (ACEI) captopril to reduce pulmonary damage after radiation for lung cancer. Despite significant effort, the trial did not analyze a sufficient number of patients to test the hypothesis due to early study closure. However, it did show the safety of the ACEI mitigation approach and the use of newer ACEIs, started during radiotherapy, may solve the accrual problems. OBJECTIVES: The primary objective of NRG Oncology RTOG 0123 was to test the ability of the angiotensin converting enzyme inhibitor (ACEI) captopril to alter the incidence of pulmonary damage after radiation therapy for lung cancer; secondary objectives included analyzing pulmonary cytokine expression, quality of life, and the long-term effects of captopril. METHODS: Eligible patients included Stage II-IIIB non-small cell lung cancer, Stage I central NSCLC, or limited-stage small-cell. Patients who met eligibility for randomization at the end of radiotherapy received either captopril or standard care for one year. The captopril was to be escalated to 50 mg TID. Primary endpoint was incidence of Grade 2+ radiation-induced pulmonary toxicity in the first year. RESULTS: 81 patients were accrued between 6/2003 and 8/2007. Given the low accrual rate, the study was closed early. No significant safety issues were encountered. Eight patients were ineligible for registration or withdrew consent prior to randomization and 40 patients were not randomized post-radiation. Major reasons for non-randomization included patients' refusal and physician preference. Of the 33 randomized patients, 20 were analyzable (13 observation, 7 captopril). The incidence of Grade 2+ pulmonary toxicity attributable to radiation therapy was 23% (3/13) in the observation arm and 14% (1/7) in the captopril arm. CONCLUSION: Despite significant resources and multiple amendments, NRG Oncology RTOG 0123 was unable to test the hypothesis that captopril mitigates radiation-induced pulmonary toxicity. It did show the safety of such an approach and the use of newer ACEIs started during radiotherapy may solve the accrual problems.

OBJECTIVES To evaluate the ability of measures of coagulopathy and acidosis to predict complications. We hypothesize that increased coagulopathy and acidosis over the first 60 hours of hospitalization will result in increased rates of infection and mortality. DESIGN Prospective, observational. SETTING Level 1 trauma center. PATIENTS Three hundred seventy-six skeletally mature patients with an Injury Severity Score greater than 16, who were surgically treated for high-energy fractures of the femur, pelvic ring, acetabulum, and/or spine. MAIN OUTCOME MEASUREMENTS Data included measures of acidosis, pH, lactate, and base excess, and measures of coagulopathy, Prothrombin (PT), Partial Throunboplastin Time (PTT), International Normalized Ratio (INR), and platelets. Complications including pneumonia, deep venous thrombosis, pulmonary embolism, infection, organ failure, acute renal failure, sepsis, and death were documented. RESULTS Acidosis was common on presentation (88.8%) and decreased over 48 hours (50.4%). Incidence of coagulopathy increased over 48 hours (16.3%-34.3%). Coagulopathy on presentation was associated with complications (54.0% vs. 27.7%) including pneumonia, acute renal failure, multiple organ failure, infection, sepsis, and death. Acidosis was associated with complications if it persisted later in the hospital course. CONCLUSION Coagulopathy on presentation is a stronger predictor of complications, sepsis, and death than acidosis. During the first 48 hours, unresolved acidosis increased the risk of complications and sepsis. Complications were most related to higher Injury Severity Score. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To compare single versus multiple procedures in the same surgical setting. We hypothesized that complication rates would not be different and length of stay would be shorter in patients undergoing multiple procedures. DESIGN Prospective, cohort. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS A total of 370 patients with high-energy fractures were treated after a standard protocol for resuscitation to lactate

We developed a protocol to determine the timing of definitive fracture care based on the adequacy of resuscitation. Inception of this project required a multidisciplinary group, including physicians from anesthesiology, general trauma and critical care, neurosurgery, orthopaedic spine, and orthopaedic trauma. The purposes of this study were to review our initial experience with adherence to protocol recommendations and to assess barriers to implementation.Prospective.Level 1 trauma center.Definitive fixation of pelvis, acetabulum, spine, and femur fractures within 36 hours of injury, based on laboratory parameters for acidosis.Three hundred five consecutive skeletally mature patients with Injury Severity Score ≥ 16 (mean, 26.4) and 346 fractures of the proximal or diaphyseal femur (n = 152), pelvic ring (n = 56), acetabulum (n = 44), and/or spine (n = 94) were treated surgically. Adherence to the protocol was defined as definitive fixation within 36 hours of injury in resuscitated patients. All patients were adequately resuscitated within that time. Patient demographic and injury characteristics, date and time of presentation, and reasons for delay were recorded.Two hundred fifty-one patients (82%) with 287 fractures were treated according to the protocol, whereas 54 patients (18%) with 59 fractures were definitively stabilized on a delayed basis (mean, 90 hours). Delay was not related to patient age, Injury Severity Score, day of week, or time of presentation. Before implementation of this protocol, 76% were treated on a delayed basis, demonstrating improvement for each fracture type: spine (79% of previous patients with delay), pelvis (57%), acetabulum (72%), and femur (22%); all P0.0001 for more frequently delayed surgery before the protocol. Surgeon choice to delay the procedure accounted for 67% of reasons for delay. Other reasons included intensivist choice (13%), operating room availability (7.4%), patient choice (3.7%), severe head injury (5.6%), or cardiac issues (3.7%). Our trauma center and surgeons became more accustomed to the protocol and had fewer delays over time; 10% were delayed 2 years after implementation.Management of trauma patients with injury to multiple systems requires teamwork among providers from related specialties and hospital support, in terms of operating room access, with appropriate ancillary personnel and equipment. Our system adjusted quickly to the protocol. Surgeon preference was the most common reason for delayed fixation, but within 24 months, only 10% of fractures were treated on a delayed basis, as long as patients were resuscitated.

Objective: To determine the diagnostic potential of prevertebral soft-tissue (PVST) swelling in cervical spine ligamentous injury (LI). Background: PVST swelling in the cervical spine is a historical indicator of cervical spine injury; however, at present, there are no limited objective criteria to use PVST swelling to guide clinical decision-making regarding cervical spine LI. This study investigates PVST thickness as a screening measure for cervical spine LI with a potential to identify indications for advanced imaging. Methods: The registry at an urban level 1 trauma center was queried for cervical spine injuries between 2010 and 2016. Twenty-nine patients with LIs who had both CT and MRI available were included. Fifty-nine patients with bony injury (BI) were also included, and 99 patients undergoing CT of the cervical spine after blunt trauma without evidence of cervical spine injury were included as control patients. Results: PVST swelling >11.5 mm at C7 was 89.7% sensitive (72.7% to 97.8%) and 51.5% specific (41.3% to 61.7%) for LI. In men, a PVST thickness of 11.5 mm at C7 was 96% sensitive (79.7% to 99.9%) and 46.2% specific (32.2% to 60.5%) for LI. Patients with LI were more likely to be men (86.2% versus 52.5% control, P < 0.01). 86.2% of patients with LI (25 of 29) had associated BI. Patients who had LI and no associated BI (n = 4) were all men, and all had PVST thickness >11.5 mm at C7 (avg. PVST 17.7 mm ± 2.5). Conclusion: C7 PVST thickness >11.5 mm was highly sensitive but poorly specific for cervical spine LI. This threshold may represent an appropriate PVST thickness to rule out LI because patients with PVST ≤11.5 mm are unlikely to have cervical spine LI and may not benefit from MRI.

Study design Retrospective review. Objective The objective of this study was to evaluate the ability of the American Spinal Injury Association (ASIA) Impairment Scale and neurological level of injury to predict the need for mechanical ventilation as well as tracheostomy. Summary of background data High-level cervical spinal cord injuries, high Injury Severity Score, and low Glasgow Coma Scale have been shown to predict tracheostomy. Methods A total of 383 patients with fractures, dislocations, or ligamentous injury of the cervical spine were included in the study. Charts were reviewed to determine demographics, Injury Severity Score, Glasgow Coma Scale, presence and severity of chest injuries, length of hospital stay, intensive care unit stay, mechanical ventilation time, and mortality. Results Fifty-nine patients (15.4%) underwent tracheostomy. An ASIA Impairment Scale of A had a specificity of 98.8% and sensitivity of 32.2% for predicting the need for tracheostomy. This yielded a 1.2% false-positive rate. The ASIA Impairment Scale remained the most significant predictor after regression for Injury Severity Score, Glasgow Coma Scale, and Chest Abbreviated Injury Scale. Neurological level of injury was not a significant predictor of tracheostomy. Conclusion An ASIA Impairment Scale of A at any level of injury is a specific predictor of the need for tracheostomy with a low false-positive rate. Given the relatively low risk of early tracheostomy and the potential benefits, an ASIA Impairment Scale of A would be a sensible early criterion to determine the need for tracheostomy. Level of evidence 3.

STUDY DESIGN The thoracolumbar injury classification system (TLICS) was evaluated in 20 consecutive pediatric spine trauma cases. OBJECTIVE The purpose of this study was to determine the reliability and validity of the TLICS in pediatric spine trauma. SUMMARY OF BACKGROUND DATA The TLICS was developed to improve the categorization and management of thoracolumbar trauma. TLICS has been shown to have good reliability and validity in the adult population. METHODS The clinical and radiographical findings of 20 pediatric thoracolumbar fractures were prospectively presented to 20 surgeons with disparate levels of training and experience with spinal trauma. These injuries were consecutively scored using the TLICS. Cohen unweighted κ coefficients and Spearman rank order correlation values were calculated for the key parameters (injury morphology, status of posterior ligamentous complex, neurological status, TLICS total score, and proposed management) to assess the inter-rater reliabilities. Five surgeons scored the same cases 3 months later to assess the intra-rater reliability. The actual management of each case was then compared with the treatment recommended by the TLICS algorithm to assess validity. RESULTS The inter-rater κ statistics of all subgroups (injury morphology, status of the posterior ligamentous complex, neurological status, TLICS total score, and proposed treatment) were within the range of moderate to substantial reproducibility (0.524-0.958). All subgroups had excellent intra-rater reliability (0.748-1.000). The various indices for validity were calculated (80.3% correct, 0.836 sensitivity, 0.785 specificity, 0.676 positive predictive value, 0.899 negative predictive value). Overall, TLICS demonstrated good validity. CONCLUSION The TLICS has good reliability and validity when used in the pediatric population. The inter-rater reliability of predicting management and indices for validity are lower than those in adults with thoracolumbar fractures, which is likely due to differences in the way children are treated for certain types of injuries. TLICS can be used to reliably categorize thoracolumbar injuries in the pediatric population; however, modifications may be needed to better guide treatment in this specific patient population. LEVEL OF EVIDENCE 4.

The management of patients with metastatic melanoma remains a difficult problem. Although potentially curable when diagnosed early, the median survival of patients with metastatic disease is generally

Background The early appropriate care (EAC) protocol and clinical grading system (CGS) propose criteria that suggest timing of definitive fracture fixation by assessing risk for complications. This study applies these criteria to a cohort of patients with orthopedic injuries and determines clinical outcomes for groups stratified by risk and timing of fracture fixation. Methods This retrospective work was performed at a Level I trauma center. Patients with operative femur, pelvis, acetabulum, and/or thoracolumbar spine injuries were included. Fractures were treated surgically, either early or delayed. Patients were retrospectively categorized into low- or high-risk groups using the EAC protocol and described as stable, borderline, unstable, or in extremis using a modified CGS (mCGS). Results In the EAC analysis, low-risk patients treated early had fewer complications compared with delayed treatment. Among high-risk patients, no significant difference was noted. With the use of the mCGS, stable patients treated early had fewer complications compared with delayed patients. No difference in complications was detected for unstable and in extremis patients. Borderline patients treated early had fewer complications compared with delayed treatment, although results were not supported by sensitivity analysis. Conclusion The EAC protocol can effectively distinguish patients who are at high risk for complications if treated early. Early treatment in the low-risk group was associated with fewer complications. The mCGS differentiates stable patients who benefit from early definitive treatment of fractures as well as severely injured patients (unstable or in extremis) who may benefit from damage-control orthopedics. Borderline patients may also benefit from early definitive treatment, but criteria defining borderline patients require further study. Level of evidence Prognostic study, level III.

Study Design. Case series. Objective. To investigate if the thoracolumbar injury classification and severity score (TLICS) system is effective in evaluating low lumbar injuries. Summary of Background Data. The TLICS classification has been used by spine traumatologists since its introduction in 2006. The classification is predictable and consistent when dealing with thoracolumbar injuries. It is not known if the classification is effective in dealing with low lumbar injuries that tend to behave differently than thoracolumbar injuries. TLICS is yet to be clinically validated. There are no reports of its use for low lumbar injuries alone. Methods. For this case series, 20 low lumbar injuries were graded using the TLICS system by 15 fellowship-trained orthopedic spine and neurosurgeons. Interobserver reliability was graded using κ values. The reviewers were also asked 4 clinical questions regarding diagnosis and treatment of these injuries. Results. When using the TLICS system for low lumbar injuries, there was “fair” reliability among the reviewers. Concerning the final TLICS score, there was 28% agreement with a κ of 0.245. Concerning fracture morphology, there was 58% agreement with a κ value of 0.394. When evaluating the posterior ligamentous complex, there was 56% agreement with a κ value of 0.328. The reviewers did agree consistently on determining the patient's neurological status. The data showed 94% agreement with a κ of 0.818. When looking at L3 injuries by themselves, the reliability of TLICS improved significantly. Conclusion. The authors think that there are factors involved in treating low lumbar injuries that are not inclusive to the TLICS system. Overall, there was only “fair” reliability for low lumbar injuries. The maintenance of lordosis and global sagittal alignment is paramount when dealing with low lumbar injuries and not considered in TLICS. L3 injuries tend to behave like thoracolumbar injuries but there is a wide variation in classification between L4–L5 and thoracolumbar injuries. Conclusion. Level of Evidence: 4

Background: Osteonecrosis and posttraumatic arthritis are common after talar neck fracture. We hypothesized that delay of definitive fixation would not increase the rate of osteonecrosis, but that the amount of initial fracture displacement, including subtalar and/or tibiotalar dislocations, would be predictive. We investigated the possibility of dividing the Hawkins type-II classification into subluxated (type-IIA) and dislocated (type-IIB) subtalar joint subtypes. Methods: The cases of eighty patients with eighty-one talar neck and/or body fractures who had a mean age of 36.7 years were reviewed. The fractures included two Hawkins type-I, forty-four type-II (twenty-one type-IIA and twenty-three type-IIB), thirty-two type-III, and three type-IV fractures. Open fractures occurred in twenty-four patients (30%). Results: One deep infection, two nonunions, and two malunions occurred. After a mean of thirty months of follow-up, sixteen of sixty-five fractures developed osteonecrosis, but 44% of them revascularized without collapse. Osteonecrosis never occurred in fractures without subtalar dislocation (Hawkins type I and IIA), but 25% of Hawkins type-IIB patterns developed osteonecrosis (p = 0.03), and 41% of Hawkins type-III fractures developed osteonecrosis (p = 0.004). Osteonecrosis occurred after 30% of open fractures versus 21% of closed fractures (p = 0.55). Forty-six fractures were treated with urgent open reduction and internal fixation (ORIF) at a mean of 10.1 hours, primarily for open fractures or irreducible dislocations. With the numbers studied, the timing of reduction was not related to the development of osteonecrosis. Thirty-five patients had delayed ORIF (mean, 10.6 days), including ten with Hawkins type-IIB and ten with Hawkins type-III fractures initially reduced by closed methods, and one (5%) of the twenty developed osteonecrosis. Thirty-five patients (54%) developed posttraumatic arthritis, including 83% of those with an associated talar body fracture (p < 0.0001) and 59% of those with Hawkins type-III injuries (p < 0.01). Conclusions: Following talar neck fracture, osteonecrosis of the talar body is associated with the amount of the initial fracture displacement, and separating Hawkins type-II fractures into those without (type IIA) and those with (type-IIB) subtalar dislocation helps to predict the development of osteonecrosis as in this series. It never occurred when the subtalar joint was not dislocated. When it does develop, osteonecrosis often revascularizes without talar dome collapse. Delaying reduction and definitive internal fixation does not increase the risk of developing osteonecrosis. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. Peer Review This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.

Study design Retrospective cohort. Objective The purpose of this study is to determine the fusion rates of a consecutive series of anterior cervical decompressions and fusions with allograft patella using both static and dynamic plates. Summary of background data Anterior cervical diskectomy and fusion (ACDF) has been shown to improve symptoms of radiculopathy and myelopathy. The gold standard for obtaining fusion is using autogenous iliac crest bone graft (ICBG). The complication rate of using ICBG can be as high as 20%. To minimize this morbidity, various forms of allograft are presently used. We have used patellar allograft that we hypothesize exhibits a good combination of strength and sufficient porosity to facilitate fusion. Methods A consecutive series of 179 levels in 136 patients who underwent single and multilevel ACDF with allograft patella were retrospectively investigated. Final follow-up lateral cervical spine radiographs were evaluated for evidence of bony fusion. Fusions were graded independently by 2 of the investigators according to an interbody fusion classification proposed by Bridwell and colleagues, Spine, 1995. Fusion rates were compared with historical controls for single-level ACDF with autogenous ICBG and plating. Multivariate analysis was used to evaluate plate type, smoking, revision rate, and Odom's criteria compared with fusion. Results Ninety-one consecutive single and 81 multilevel anterior cervical decompression and fusions with allograft patella were reviewed. Demographics were similar (average age 47.75 y). Average follow-up was 19.3 months. Fusion rates were 86% (159/179). Our revision rate was 8%. Eighty-one percent (85/98) union rate was noted in the single-level group, and 85% (69/81 levels) or 74% (28/38 patients) in the multilevel group. Conclusions Fusion rates were 86%. Plate design (static vs. dynamic) did not seem to affect fusion rates or clinical outcomes. There was a higher nonunion rate at the most inferior level of the multilevel fusions. Nonunions in the dynamic group were more commonly revised and had more kyphosis at final follow-up.

Chemotherapy and endocrine treatments for breast cancer are believed to increase risk of osteoporosis by causing early menopause in premenopausal women and by further depleting estrogen levels in postmenopausal women. Multivariate analyses were used to evaluate the contributions of 7 predictors (age, body mass index [BMI], family history of osteoporosis, months since menopause, past use of chemotherapy, and current use of tamoxifen or aromatase inhibitors) in explaining variability in bone mineral density (BMD) at the hip and the spine and bone turnover in 249 postmenopausal women who are breast cancer survivors. This report was an analysis of baseline data from a federally funded (1 R01 NR07743-01A1) intervention study on osteoporosis prevention. Mean age of the women was 58.5 years, and average BMI was 26.7 kg/m; 98% were white. All had measurable bone loss, 167 had chemotherapy, 76 were on tamoxifen, and 21 were on aromatase inhibitors. Women with higher BMI had higher BMD at the hip (P < .001) and the spine (P = .004). Women on tamoxifen had lower measures of bone formation (Alkphase B) (P < .001), suggesting less bone turnover, and higher BMD at the hip (P = .035). There was a trend for women who had received chemotherapy to have lower BMD at the spine (P = .06). The implications of these findings are discussed in the article.

Background— The causes of aortic regurgitation (AR) severe enough to warrant aortic valve replacement (AVR) have received little attention in the last 20 years. Methods and Results— We analyzed the causes of pure AR in 268 patients >20 years of age having isolated AVR at Baylor University Medical Center from 1993 to 2005 that was unassociated with mitral stenosis, mitral valve replacement, or a previous operation involving a cardiac valve or ascending aorta. In 122 patients (46%), the AR resulted from a problem with the aortic valve: congenital malformation unassociated with infective endocarditis, 66 patients (54%); infective endocarditis, 46 patients (38%; 15 with bicuspid valves); probable rheumatic heart disease, 8 patients (6%); and miscellaneous, 2 patients (2%). In the other 146 patients (54%), the AR was the consequence of a condition affecting the ascending aorta: dissection, 28 patients (19%); the Marfan syndrome or its forme fruste variety, 15 patients (10%); aortitis, 12 patients (8%), and in the remaining 91 patients (62%), the cause of the AR was not determined. This latter group was the oldest (mean age 66 years), 83 (91%) had hypertension, 26 (29%) had small calcific deposits in the valve cusps, and 46 (51%) had simultaneous coronary artery bypass grafting. Conclusions— The causes of pure AR severe enough to warrant isolated AVR are diverse. The most common category in this study was “cause unclear.”

STUDY DESIGN Blinded assessment by multiple observers of consecutive case series. OBJECTIVES Measure the reliability of a new system of determining stability in subaxial cervical spine injuries. SUMMARY OF BACKGROUND DATA Classification is fundamental to allow communication, determine prognosis, and direct treatment. Current systems have many limitations, including difficultly of use, lack of proven reliability and validity, and no assessment of stability. A new system to assess instability is proposed. METHODS A literature review of the most commonly described classification systems is reported. The Cervical Spine Injury Severity Score was tested for reliability by 10 examiners who graded 35 consecutive cases of cervical trauma. Plain radiographs and CT were saved as read using Efilm Lite in random order. Each was scored and intraobserver and interobserver agreement was measured using intraclass correlation coefficients (ICC). RESULTS Intraobserver agreement was excellent with ICC ranging from 0.97 to 0.99. Interobserver agreement was also excellent with mean 0.80 ranging from 0.75 to 0.98. CONCLUSION A new cervical spine classification system of injury is paramount to treatment and outcomes. A new system may increase reliability and therefore allow more accurate determination of stability and dictate treatment.

Purpose The authors assessed the effectiveness of a videodisc film file compared with a conventional film file for teaching radiology to medical students. Methods Fourth-year medical students (N = 134) studied 116 cases selected from the American College of Radiology Learning File. Half the students studied 58 skeletal cases using conventional films and half studied the same cases on a videodisc system. Student groups were then switched and those who studied skeletal cases on films studied 58 chest cases on videodisc and vice versa. Students received the same skeletal and chest tests and completed a questionnaire. Results For both skeletal and chest radiology, students studying films scored minimally higher than students using the videodisc. Students rated films superior to the videodisc for amount learned, convenience of use, and ability to detect lesions. Conclusions Conventional film and videodisc methods resulted in similar levels of learning; however, students perceived conventional films to be a superior learning experience.