Risk for Post-Spinal Surgery Complications Associated with Pre-Operative Blood Transfusions

Introduction: The frequency of spinal surgeries has increased dramatically in the United States over the past decade and, as with all surgeries, spinal procedures carry inherent risks for complications after the operation. Recently, it has been recognized that procedures in which intra-operative/post-operative blood transfusions are administered carry a higher risk of postoperative morbidity and increased length of hospital stay (Seisean et al.). Despite this, there is little literature, currently, analyzing post-operative complications associated with blood transfusions taking place 72 hours prior to spinal operations. The aim of this study was to investigate the prevalence of pre-operative blood transfusions in spinal surgeries and elucidate the associations that exist between those transfusions and post-operative complications. Materials & Methods: We retrospectively analyzed cases of spinal surgeries between 2005 and 2014 from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database with the exception of 2009 due to incomplete data. A total of 37,201 patients who had undergone spinal procedures were studied. Patients receiving pre-operative blood transfusions within 72 hours of surgery were documented. Demographic factors, including sex and age, were noted. Comorbidities included in this analysis include body mass index (BMI) and American Society of Anesthesiologists (ASA) score. Post-operative complications were stratified into major and minor categories. Chi-squared test, Fisher\u27s exact test, and ANOVA were used to perform univariate testing where appropriate, while multivariate analyses were performed to determine independent risk factors for complications. Results:With the exception of pneumonia (p=0.096), blood transfusions prior to spinal surgeries were associated with increased risk for all major and minor complication criteria analyzed, with major complications including myocardial infarction (MI), deep venous thrombosis (DVT), pulmonary embolism (PE), stroke, peripheral nerve injury, deep wound infection, organ cavity infection, sepsis, and death (p Discussion: Overall, patients receiving blood transfusions within 72 hours prior to undergoing spinal procedures had increased rates of several post-operative complications. Among these complications, the most notable include superficial and deep wound infections, MI, pneumonia, DVT, stroke, and even death. Armed with this knowledge, surgeons would better be able to predict, and therefore mitigate, such post-operative complications in these patients. Future research in this area, directed toward stratification of risk based on the patient’s need for pre-operative blood transfusion and procedure type, would provide further insight into preventing post-operative complications after spinal surgeries

Patterns and Perceptions of Smartphone Use Among Academic Neurologists in the United States: Questionnaire Survey.

BackgroundSmartphone technology is ubiquitous throughout neurologic practices, and numerous apps relevant to a neurologist's clinical practice are now available. Data from other medical specialties suggest high utilization of smartphones in routine clinical care. However, the ways in which these devices are used by neurologists for patient care-related activities are not well defined.ObjectiveThis paper aims to characterize current patterns of smartphone use and perceptions of the utility of smartphones for patient care-related activities among academic neurology trainees and attending physicians. We also seek to characterize areas of need for future app development.MethodsWe developed a 31-item electronic questionnaire to address these questions and invited neurology trainees and attendings of all residency programs based in the United States to participate. We summarized descriptive statistics for respondents and specifically compared responses between trainees and attending physicians.ResultsWe received 213 responses, including 112 trainee and 87 attending neurologist responses. Neurology trainees reported more frequent use of their smartphone for patient care-related activities than attending neurologists (several times per day: 84/112, 75.0% of trainees; 52/87, 59.8% of attendings; P=.03). The most frequently reported activities were internet use, calendar use, communication with other physicians, personal education, and health care-specific app use. Both groups also reported regular smartphone use for the physical examination, with trainees again reporting more frequent usage compared with attendings (more than once per week: 35/96, 36.5% of trainees; 8/58, 13.8% of attendings; P=.03). Respondents used their devices most commonly for the vision, cranial nerve, and language portions of the neurologic examination. The majority of respondents in both groups reported their smartphones as "very useful" or "essential" for the completion of patient care-related activities (81/108, 75.0% of trainees; 50/83, 60.2% of attendings; P=.12). Neurology trainees reported a greater likelihood of using their smartphones in the future than attending neurologists ("very likely": 73/102, 71.6% of trainees; 40/82, 48.8% of attendings; P=.005). The groups differed in their frequencies of device usage for specific patient care-related activities, with trainees reporting higher usage for most activities. Despite high levels of use, only 12 of 184 (6.5%) respondents reported ever having had any training on how to use their device for clinical care. Regarding future app development, respondents rated vision, language, mental status, and cranial nerve testing as potentially being the most useful to aid in the performance of the neurologic examination.ConclusionsSmartphones are used frequently and are subjectively perceived to be highly useful by academic neurologists. Trainees tended to use their devices more frequently than attendings. Our results suggest specific avenues for future technological development to improve smartphone use for patient care-related activities. They also suggest an unmet need for education on effectively using smartphone technology for clinical care

Governo e governance dei servizi di pubblica utilità per lo sviluppo umano:un'introduzione

Le presenti note introducono l’approfondimento monografico di questo numero della Rivista. Vanno quindi delineati i presupposti e il campo di indagine dell’attività di ricerca che ha favorito la realizzazione dei lavori presentati. A tale scopo, questa introduzione si concentrerà su quattro passaggi principali. Inizialmente, nel paragrafo 1 tratteggio i fattori di complessità e le idee chiave funzionali ad una governance innovativa che rendono necessaria l’adozione di modello più articolato per l’analisi dell’organizzazione della conoscenza all’interno ed all’esterno delle imprese. Successivamente, nel paragrafo 2, suggerisco un possibile metodo con cui sviluppare riflessioni periodiche ad ampio raggio all’interno delle imprese su questo ed altri temi. Nel paragrafo 3 mi concentro su alcuni fatti stilizzati che vengono evidenziati nella letteratura sull’interazione tra government e governance nella fornitura di servizi pubblici locali. Infine, nel paragrafo 4 cercherò di delineare i contorni di una relazione complessa, ma essenziale, tra government e governance, funzionale allo sviluppo umano. Il consolidamento del principio di sussidiarietà orizzontale e la crisi del modello basato sul government hanno favorito l’af-fermarsi di una nuova filosofia dell’esercizio dell’autorità: la governance, intesa come «[...] sistema multicentrico costituito da molti attori, per lo più organizzazioni sociali, [...] che va emergendo ora come fonte rivale di autorità, ora come risorsa cooperativa, altre volte ancora come competitor e infine come interlocutore» (Iannone, 2005, p. 78) nei confronti del modello basato sul government. La governance si fonda sull’efficacia della regolazione, piuttosto che sulle competenze, generando un insieme di regole di condotta nell’ambito delle quali è concesso un ampio margine di libertà ai privati. Tuttavia, nel nuovo contesto determinato dalla crisi globale, decollata nel 2007 e tuttora in atto, si sta manifestando una nuova contraddizione, acuita dalla crisi europea, tra government e governance, che contribuisce a sfumare e rivedere i confini e gli ambiti di competenza tra queste due forme di esercizio dell’autorità. L’auspicio è che questo approfondimento si presti alla realizzazione di un confronto tra cultura accademica e cultura d’impresa, continuativo nel tempo e produttivo di risultati, anche operativi, sullo sviluppo locale

Point-of-care Ultrasound Diagnosis of Bilateral Patellar Tendon Rupture

Musculoskeletal complaints are one cornerstone of urgent issues for which orthopedic and emergency physicians provide care. Ultrasound can be a useful diagnostic tool to help identify musculoskeletal injuries. We describe a case of bilateral patellar tendon rupture that presented after minor trauma, and had the diagnosis confirmed at the bedside by point-of-care ultrasound.Physicians caring for patients with orthopedic injuries should be familiar with the use of ultrasound to diagnose tendon ruptures

THE AMERICAN SOCIETY OF MECHANICAL ENGINEERS TRANSONIC COMPRESSOR INFLUENCES ON UPSTREAM El 1111111H' HU SURFACE PRESSURES WITH AXIAL SPACING

ABSTRACT A set of inlet guide vane (IGV) unsteady surface pressure measurements is presented. The unsteady aerodynamic effects of a highly loaded, high speed downstream compression stage on the upstream inlet guide vane stator surface pressures are characterized through experimental and computational analysis. The axial spacing between the IGV and rotor was varied between 12%, 26%, and 56% of the IGV chord for a 105% speed, peak efficiency operating condition, which is transonic. Unsteady IGV surface pressures were acquired for two spanwise locations on both blade surfaces. The largest unsteady surface pressure magnitudes were obtained at the 12% axial spacing configuration and 95% chord location. In general, spanwise variations were found to be important. The upstream bow shock effect is non-linear in character. Comparisons to a twodimensional, non-linear unsteady multi-blade row Navier-Stokes analysis at 50% span show a good agreement with the IGV unsteady surface pressure results and higher harmonic content. The results of the study indicate significant variations in the IGV unsteady loading caused by changes in axial spacing

Comparison of Coronal Subtalar Alignment between Adult Acquired Flatfoot Deformity Patients and Controls Using Standard CT and Weight-Bearing Multiplanar Imaging

Category: Hindfoot Introduction/Purpose: In a previous study using novel multiplanar weight-bearing imaging (MP-WB), the inferior talus-superior talus (inftal-suptal) angle reliably evaluated the coronal orientation of the subtalar joint axis and was significantly greater in stage II adult-acquired flatfoot deformity (AAFD) patients compared to controls. Since the inftal-suptal angle relies solely on the morphology of the talus, which is theoretically unchanged at the time of flatfoot reconstruction, we hypothesized that it should be similar in pre-operative MP-WB scans compared to post-operative non-weight-bearing standard CT scans of a stage II AAFD group. We secondly hypothesized that the post-operative CT angle of AAFD patients is significantly greater than the pre-operative CT scan angle of controls. Such information could allow for the assessment of AAFD with a less expensive and more readily available tool. Methods: Patients enrolled in the authors’ institution’s Foot and Ankle Registry with a diagnosis of stage II (flexible) AAFD and undergoing flatfoot reconstruction surgery were identified. Both MP-WB scans and post-operative CT scans were obtained in the flatfoot group to assess deformity and healing of the lateral column lengthening or tarsometatarsal fusion, respectively. A control group with pre-operative CT scans for lisfranc injuries (unrelated forefoot pathology) and normal hindfoot alignment on exam after final healing was identified. Standard weight-bearing radiographic imaging was obtained pre-operatively in the AAFD group and after final healing in the control, and 5 previously-established radiographic parameters were measured. The inftal-suptal angle was measured in CT scans of the control and AAFD groups, and in MP-WB scans of the AAFD group. Differences in CT inftal- suptal and radiographic parameters between AAFD and controls were assessed with independent samples t-tests. The correlation between inftal-suptal angles measured by MP-WB and CT in the AAFD group was assessed with Pearson’s correlation coefficients. Results: 38 stage II AAFD patients (38 feet; 53% female; age 56.7±11.7 years) undergoing flatfoot reconstruction surgery from November, 2008 to December, 2014 and with MP-WB scans 61.9±77.5 days pre-operatively and CT scans 51.3±8.6 days post- operatively were identified. 20 patient controls (20 feet; 45% female; age 35.7±13.4 years) with CT scans 13.8±20.5 days pre- operatively from June, 2006 to October, 2013, were evaluated. All plain radiographic parameters differed significantly between AAFD and control groups (Table 1), verifying placement of patients into their respective groups based on previously-established norms. The inftal-suptal CT angle additionally differed between the AAFD and control groups (p < 0.001). The correlation between inftal-suptal angles measured by MP-WB and CT scans was relatively weak (Pearson’s=0.29) and did not reach statistical significance (p = 0.08). Conclusion: In summary, inftal-suptal angles of AAFD patients were significantly greater than those of controls on CT scans, and MP-WB imaging proved more predictive of AAFD than CT imaging. This study confirmed that while CT scans are useful in predicting stage II AAFD, they cannot be used as a surrogate for MP-WB scans, as they do not fully capture the amount of valgus. The most probable explanation of this is the re-formatting of CT scans into sagittal and coronal planes or a difference in the position of the foot during the scan, both leading to a potential difference in the planes of CT imaging and MP-WB imaging