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The First AO Classification System for Fractures of the Craniomaxillofacial Skeleton: Rationale, Methodological Background, Developmental Process, and Objectives.

ABSTRACT: Validated trauma classification systems are the sole means to provide the basis for reliable documentation and evaluation of patient care, which will open the gateway to evidence-based procedures and healthcare in the coming years. With the support of AO Investigation and Documentation, a classification group was established to develop and evaluate a comprehensive classification system for craniomaxillofacial (CMF) fractures. Blueprints for fracture classification in the major constituents of the human skull were drafted and then evaluated by a multispecialty group of experienced CMF surgeons and a radiologist in a structured process during iterative agreement sessions. At each session, surgeons independently classified the radiological imaging of up to 150 consecutive cases with CMF fractures. During subsequent review meetings, all discrepancies in the classification outcome were critically appraised for clarification and improvement until consensus was reached. The resulting CMF classification system is structured in a hierarchical fashion with three levels of increasing complexity. The most elementary level 1 simply distinguishes four fracture locations within the skull: mandible (code 91), midface (code 92), skull base (code 93), and cranial vault (code 94). Levels 2 and 3 focus on further defining the fracture locations and for fracture morphology, achieving an almost individual mapping of the fracture pattern. This introductory article describes the rationale for the comprehensive AO CMF classification system, discusses the methodological framework, and provides insight into the experiences and interactions during the evaluation process within the core groups. The details of this system in terms of anatomy and levels are presented in a series of focused tutorials illustrated with case examples in this special issue of the Journal.

SUBMITTER: Audige L

PROVIDER: S-EPMC4251717 | biostudies-other | 2014 Dec

REPOSITORIES: biostudies-other

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Project description:This tutorial outlines the detailed system for fractures of the condylar process at the precision level 3 and is organized in a sequence of sections dealing with the description of the classification system within topographical subdivisions along with rules for fracture coding and a series of case examples with clinical imaging. Basically, the condylar process comprises three fracture levels and is subdivided into the head region, the condylar neck, and the condylar base. Fractures of the condylar head show typical fracture lines either within the lateral pole zone, which may lead to loss of vertical height, or medially to the pole zone, with the latter ones usually not compromising the vertical condyle to fossa relation. In condylar head fractures, the morphology is further described by the presence of minor or major fragmentation, the vertical apposition of fragments at the plane of the head fracture, the displacement of the condylar head with regard to the fossa including a potential distortion of the condylar head congruency resulting in dystopic condyle to fossa relations and the presence or absence of a loss of vertical ramus height. A specific vertical fracture pattern extending from the head to the neck or base subregion is considered. Fractures of the condylar neck and base can be differentiated according to a newly introduced one-third to two-thirds rule with regard to the proportion of the fracture line above and below the level of the sigmoid notch, which is presented in the classification article, and are basically subdivided according to the presence or absence of displacement or dislocation. In both condylar neck and base fractures, the classification is again based on the above mentioned parameters such as fragmentation, displacement of the condylar head with regard to the fossa, including dystopic condyle to fossa relations and loss of vertical ramus height, that is, according to the measurement of the condylar process. In addition, the classification assesses a sideward displacement including the respective displacement sector at the neck or base fracture site as well as the angulation of the superior main fragment and also considers a potential displacement of the caudal fragment with regard to the fossa, which may occur in fractures affecting additional fracture locations in the mandible. The design of this classification is discussed along with a review of existing classification systems. The condylar process for fracture location was defined according to the level 2 system presented in a previous tutorial in this special issue.

Project description:OBJECTIVE:The premise of the National Institute of Mental Health Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP) is to combine state-of-the-art pharmacologic and psychosocial treatments delivered by a well-trained, multidisciplinary team in order to significantly improve the functional outcome and quality of life for first-episode psychosis patients. The study is being conducted in non-academic (ie, real-world) treatment settings, using primarily extant reimbursement mechanisms. METHOD:We developed a treatment model and training program based on extensive literature review and expert consultation. Our primary aim is to compare the experimental intervention to "usual care" on quality of life. Secondary aims include comparisons on remission, recovery, and cost-effectiveness. Patients 15-40 years old with a first episode of schizophrenia, schizoaffective disorder, schizophreniform disorder, psychotic disorder not otherwise specified, or brief psychotic disorder according to DSM-IV and no more than 6 months of treatment with antipsychotic medications were eligible. Patients are followed for a minimum of 2 years, with major assessments conducted by blinded, centralized raters using live, 2-way video. We selected 34 clinical sites in 21 states and utilized cluster randomization to assign 17 sites to the experimental treatment and 17 to usual care. Enrollment began in July 2010 and ended in July 2012 with 404 subjects. The results of the trial will be published separately. The goal of the article is to present both the overall development of the intervention and the design of the clinical trial to evaluate its effectiveness. CONCLUSIONS:We believe that we have succeeded in both designing a multimodal treatment intervention that can be delivered in real-world clinical settings and implementing a controlled clinical trial that can provide the necessary outcome data to determine its impact on the trajectory of early phase schizophrenia. TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT01321177.

Project description:ImportancePregnancy induces unique physiologic changes to the immune response and hormonal changes leading to plausible differences in the risk of developing post-acute sequelae of SARS-CoV-2 (PASC), or Long COVID. Exposure to SARS-CoV-2 during pregnancy may also have long-term ramifications for exposed offspring, and it is critical to evaluate the health outcomes of exposed children. The National Institutes of Health (NIH) Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC aims to evaluate the long-term sequelae of SARS-CoV-2 infection in various populations. RECOVER-Pregnancy was designed specifically to address long-term outcomes in maternal-child dyads.MethodsRECOVER-Pregnancy cohort is a combined prospective and retrospective cohort that proposes to enroll 2,300 individuals with a pregnancy during the COVID-19 pandemic and their offspring exposed and unexposed in utero, including single and multiple gestations. Enrollment will occur both in person at 27 sites through the Eunice Kennedy Shriver National Institutes of Health Maternal-Fetal Medicine Units Network and remotely through national recruitment by the study team at the University of California San Francisco (UCSF). Adults with and without SARS-CoV-2 infection during pregnancy are eligible for enrollment in the pregnancy cohort and will follow the protocol for RECOVER-Adult including validated screening tools, laboratory analyses and symptom questionnaires followed by more in-depth phenotyping of PASC on a subset of the overall cohort. Offspring exposed and unexposed in utero to SARS-CoV-2 maternal infection will undergo screening tests for neurodevelopment and other health outcomes at 12, 18, 24, 36 and 48 months of age. Blood specimens will be collected at 24 months of age for SARS-CoV-2 antibody testing, storage and anticipated later analyses proposed by RECOVER and other investigators.DiscussionRECOVER-Pregnancy will address whether having SARS-CoV-2 during pregnancy modifies the risk factors, prevalence, and phenotype of PASC. The pregnancy cohort will also establish whether there are increased risks of adverse long-term outcomes among children exposed in utero.Clinical trials.gov identifierClinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT05172011.

Project description:Background: Problem-based learning (PBL) is an essential element of the curriculum of the Medical University of Vienna (MUV) and is performed in an eight steps model with: clarifying, defining, analysing, shifting & sorting, identifying learning objectives, going to learn and coming back to talk and feedback. With an annual intake of up to 740 students the MUV has to recruit PBL tutors from various academic backgrounds including undergraduate near-peer students. Therefore, we were interested to see whether a tutor's academic background had an influence on the resulting PBL sessions as reflected by the percentage of learning objectives (LOs) which were actually achieved in relation to the intended LOs. Methods: For each PBL session “intended learning objectives” (ILOs) were defined. ILOs were communicated to all tutors by means of PBL session guides in order to provide homogenous learning opportunities to all students. However, it was not mandatory to reach all ILOs. The PBL coordination regarded a range of two thirds to three quarters of ILOs as a desirable goal. For analysis we retrieved data concerning ILOs, characteristics of tutors and PBL groups from the institution's PBL quality assurance system.Results: From 2012-2014, 216 PBL groups were facilitated by 106 tutors with different academic backgrounds. On average, 70.8% (95% CI: 69.2-72.5%) of the ILOs were achieved; MUV clinicians reached 74.3% (70.8-77.8%), MUV non-clinicians 74.2% (71.7-76.6%), external faculty (clinicians and non-clinicians) 68.6% (64.4-72.8%), and near-peer students 64.7% (61.8-67.7%). Statistically significant differences were found between near-peer students and MUV clinicians (p<.001) as well as MUV non-clinicians (p<.001). Conclusions: ILOs were reached within a satisfactory range. However, groups taught by near-peer students reached significantly fewer ILOs than groups taught by MUV faculty tutors. This finding raises the question whether tutor training for near-peer students should be intensified. Also, further research is needed to explore the group dynamics of student-led PBL groups.

Project description:ImportanceSARS-CoV-2 infection can result in ongoing, relapsing, or new symptoms or other health effects after the acute phase of infection; termed post-acute sequelae of SARS-CoV-2 infection (PASC), or long COVID. The characteristics, prevalence, trajectory and mechanisms of PASC are ill-defined. The objectives of the Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC in Adults (RECOVER-Adult) are to: (1) characterize PASC prevalence; (2) characterize the symptoms, organ dysfunction, natural history, and distinct phenotypes of PASC; (3) identify demographic, social and clinical risk factors for PASC onset and recovery; and (4) define the biological mechanisms underlying PASC pathogenesis.MethodsRECOVER-Adult is a combined prospective/retrospective cohort currently planned to enroll 14,880 adults aged ≥18 years. Eligible participants either must meet WHO criteria for suspected, probable, or confirmed infection; or must have evidence of no prior infection. Recruitment occurs at 86 sites in 33 U.S. states, Washington, DC and Puerto Rico, via facility- and community-based outreach. Participants complete quarterly questionnaires about symptoms, social determinants, vaccination status, and interim SARS-CoV-2 infections. In addition, participants contribute biospecimens and undergo physical and laboratory examinations at approximately 0, 90 and 180 days from infection or negative test date, and yearly thereafter. Some participants undergo additional testing based on specific criteria or random sampling. Patient representatives provide input on all study processes. The primary study outcome is onset of PASC, measured by signs and symptoms. A paradigm for identifying PASC cases will be defined and updated using supervised and unsupervised learning approaches with cross-validation. Logistic regression and proportional hazards regression will be conducted to investigate associations between risk factors, onset, and resolution of PASC symptoms.DiscussionRECOVER-Adult is the first national, prospective, longitudinal cohort of PASC among US adults. Results of this study are intended to inform public health, spur clinical trials, and expand treatment options.RegistrationNCT05172024.

Project description:ImportanceThe prevalence, pathophysiology, and long-term outcomes of COVID-19 (post-acute sequelae of SARS-CoV-2 [PASC] or "Long COVID") in children and young adults remain unknown. Studies must address the urgent need to define PASC, its mechanisms, and potential treatment targets in children and young adults.ObservationsWe describe the protocol for the Pediatric Observational Cohort Study of the NIH's RE searching COV ID to E nhance R ecovery (RECOVER) Initiative. RECOVER-Pediatrics is an observational meta-cohort study of caregiver-child pairs (birth through 17 years) and young adults (18 through 25 years), recruited from more than 100 sites across the US. This report focuses on two of five cohorts that comprise RECOVER-Pediatrics: 1) a de novo RECOVER prospective cohort of children and young adults with and without previous or current infection; and 2) an extant cohort derived from the Adolescent Brain Cognitive Development (ABCD) study ( n =10,000). The de novo cohort incorporates three tiers of data collection: 1) remote baseline assessments (Tier 1, n=6000); 2) longitudinal follow-up for up to 4 years (Tier 2, n=6000); and 3) a subset of participants, primarily the most severely affected by PASC, who will undergo deep phenotyping to explore PASC pathophysiology (Tier 3, n=600). Youth enrolled in the ABCD study participate in Tier 1. The pediatric protocol was developed as a collaborative partnership of investigators, patients, researchers, clinicians, community partners, and federal partners, intentionally promoting inclusivity and diversity. The protocol is adaptive to facilitate responses to emerging science.Conclusions and relevanceRECOVER-Pediatrics seeks to characterize the clinical course, underlying mechanisms, and long-term effects of PASC from birth through 25 years old. RECOVER-Pediatrics is designed to elucidate the epidemiology, four-year clinical course, and sociodemographic correlates of pediatric PASC. The data and biosamples will allow examination of mechanistic hypotheses and biomarkers, thus providing insights into potential therapeutic interventions.Clinical trialsgov identifierClinical Trial Registration: http://www.clinicaltrials.gov . Unique identifier: NCT05172011.

Project description:INTRODUCTION:Medications with anticholinergic activity (MACs) are used to treat diseases common in older adults. Evidence on the association between anticholinergic burden (AB) and increased risk of fractures and osteoporosis or reduced bone mineral density (BMD) is inconsistent. Our aim was to conduct a systematic review of observational studies on AB with fractures and osteoporosis or reduced BMD and provide methodological appraisal of included studies. METHODS:We searched MEDLINE, EMBASE, Science Citation Index and CENTRAL as well as grey literature from database inception up to August 2020. Eligibility criteria were: observational design, AB-exposure measured through a scale, fracture of any type or osteoporosis or reduced BMD as outcome, and reported measure of association between exposure and outcome. No restrictions related to time, language or type of data were applied. Eligibility and risk of bias assessment as well as data extraction were performed independently by two reviewers. Risk of bias of the included studies was assessed using the Newcastle-Ottawa Scale and the RTI Item Bank. RESULTS:The majority of the nine included studies had low risk of bias but heterogeneous methodology. No study used a new user design. Seven studies reported an increased risk of fractures associated with AB. In four studies using the Anticholinergic Risk Scale (ARS), adjusted risk of fractures was increased by 2-61% for ARS?=?1, by 0-97% for ARS?=?2, by 19-84% for ARS?=?3, and by 56-96% for ARS???4; in three studies the ARS was aggregated, risk increased by 39% for ARS?=?1-2 and 17% for ARS?=?2-3. Two studies reported increased risk of fractures of 14 and 52% in the highest AB-category and one study reported that change in ARS of???3 during hospitalization was associated with a 321% increased risk in fractures. Two studies did not find an association between AB and fractures. The association between AB and osteoporosis or reduced BMD could only be assessed in two studies, one reporting increased risk of lower BMD at Ward's triangle, the other reporting no association between AB and BMD T-score change at the femoral neck. DISCUSSION:Our study suggests an association between AB and increased risk of fractures with possible dose-exposure gradient in studies using the ARS. The low number of studies and heterogeneity of methods calls for the conduct of more studies. We conducted a study investigating the risk of fractures associated with anticholinergic burden, which is the result of taking one or more medication with anticholinergic activity. The results of our study suggest that persons who experience anticholinergic burden might have a higher risk of fractures. However, since we were only able to include nine studies, more studies conducted in a similar way are needed.

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The First AO Classification System for Fractures of the Craniomaxillofacial Skeleton: Rationale, Methodological Background, Developmental Process, and Objectives.

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