bluuebunny/crossref_metadata_2025 huggingface dataset:
Drama Segitiga Karpman untuk Meningkatkan Kesadaran Diri Siswa terhadap Perilaku Bullying
Authors: Debipriamuda Bashirudin , Handarini Dany M , Ramli M
Published: April 2019

Bullying is one of the events that repeatedly arises in schools and associated to varies between individuals. One of the sources of bullying is the poor self-awareness held by students. Self-awareness is one of the students skill must acquire. However, in reality there are still many students who have poor self-awareness. This study tries to investigate the effectiveness of the Karpman Drama Triangle to build up students self-awareness using Quasi Experiment Design. The research subjects consisted of 15 junior high school students who had poor self-awareness. The results of the study indicated that the Karpman Drama Triangle was useful in enhancing students self-awareness to reduce bullying behavior. It also informs us that the Karpman Drama Triangle can be an option to develop students self-awareness in reducing conflicts and bullying behavior that exists between students. The difference in the status of self-awareness between students before and after treatment is expressed is also illustrated. The Karpman Drama Triangle can be an alternative solution for handling and facilitating students who have poor social interaction and growing conflict situations towards peacefully.
International experience of agro-eco tourism development
Authors: Aslanova Dilbar
Published: April 2019

This paper investigates major feautures of the international experience of agro-eco tourism  development. On this way, major analyses were directed on the agro eco touristic points as the whole. Furthermore, article is dedicated on the international experience and ideas of agro-eco tourism from theoretical points of view.
PENGARUH CASH RATIO, TIME INTEREST EARNED DAN RETURN ON ASSET TERHADAP KEBIJAKAN DEVIDEN PADA PERUSAHAAN MANUFAKTUR YANG TERDAFTAR DI BURSA EFEK INDONESIA
Authors: Putra Gema Ade , Dewi Aminar Sutra
Published: April 2019

The aims of this study is to analyze the influence of cash ratio and return on asset toward the dividen policy. This study is focused on manufacturing company listed on Indonesia Stock Exchange from 2011-2015. The method of data collection is purposive sampling. There are 35 datas in this observation during five years. This study used secondary data from Indonesia Stock Exchange (IDX) with panel regression as statistical tool. This study shows that cash ratio has positive significant effect to dividend policy, and ROA a negatif and don't significant effect to dividend policy.
tugas makalah ibu desi
Authors: Fatahillah Gillan
Published: April 2019

Pentingnya Manajemen Proyek, sebagaimana didefinisikan di dalam A Guide tothe Project Body of Knowledge (PMBOK Guide) yang dirilis oleh Project ManagementInstitute (PMI), adalah usaha bersifat sementara yang dilakukan untuk menciptakanproduk yang unik, layanan, atau hasil. Definisi tersebut diperjelas dengan karakteristikproyek, di antaranya menghasilkan sesuatu yang unik, terdiri dari kegiatan yang salingterkait, menghasilkan deliverables berkualitas, melibatkan beberapa sumber daya, dandidorong oleh kendala keterbatasan.    Dalam empat dekade terkini, manajemen proyek telah menjadi sebuah tema pentingbagi organisasi yang mengedepankan pengelolaan proses bisnisnya secara profesionaldan modern. Fenomena ini disadari oleh organisasi berskala besar maupun kecil;pemerintah maupun swasta. Perkembangan organisasi yang terus bergerak majumengikuti perkembangan zaman berdampak pada munculnya gagasan pengembangananeka produk unggulan organisasi yang dikelola pada level proyek, program, danportofolio.      Di organisasi manapun, termasuk Direktorat Jenderal Pajak DJP, perubahansituasi dan kondisi yang dinamis kerap memicu permasalahan di dalam pengelolaanproyek maupun program. Permasalahan yang terjadi kerap mengerucut padapernyataan yang terlihat klise dan terdengar familiar di kalangan pengelola proyekmaupun program. Pengelola proyek merasa bahwa proyek yang mereka kerjakan kerapkali menghadapi “tembok tebal” berupa keterbatasan anggaran, waktu penyelesaian,dan ketersediaan sumber daya manusia (SDM). Sementara di sisi lain, tingginyaekspektasi pemangku kepentingan dan rentetan risiko maupun permasalahan, baikyang teridentifikasi ataupun tidak, siap meletup kapan saja. Terkadang tanpa peringatandini dan tak terprediksi.     Kualitas, globalisasi, dan kecepatan. Ketiganya merupakan fokus organisasi diseluruh dunia yang masing-masing pernah mengemuka di era 1980-an, 1990-an, dan2000-an. Saat ini, untuk menjadi organisasi yang terdepan dalam inovasi danmengutamakan kepuasan pelanggan, organisasi dituntut untuk mengembangkanproduk yang menghasilkan nilai tambah di mata pelanggan. Dengan skenario ini,manajemen proyek menjadi alat yang sangat penting dan kuat di tangan organisasiyang memahami kebutuhan penggunaannya dan memiliki kompetensi untukmenerapkannya.
Women's Beauty in As If It's Your Last by BLACKPINK
Authors: Zein Laila Fariha , Setiawan Adib Rifqi
Published: April 2019

This research was conducted to find out the representation of women's beauty in BLACKPINK's As If It's Your Last music video. The method used in this study is John Fiske's Semiotics with 3 levels, namely the level of reality, the level of representation and the level of ideology. The approach taken in this study is qualitative interpretive to describe the signs and symbols in the music video. It is obtained that the representation of beauty is shown through physical (outer beauty) and personality (inner beauty) which can be seen from the signs and symbols contained in the music video showing: 1) Women's beauty is a product of media engineering, 2) Beauty of women is made as a commodity object, and 3) Women's beauty is synonymous with the image of luxury.
Kecantikan Perempuan dalam As If It’s Your Last karya BLACKPINK
Authors: Zein Laila Fariha , Setiawan Adib Rifqi
Published: April 2019

Penelitian ini dilakukan untuk mengetahui representasi kecantikan perempuan dalam video musik As If It’s Your Last karya BLACKPINK. Metode yang digunakan dalam penelitian ini adalah Semiotika John Fiske dengan 3 level, yaitu level realitas, level representasi dan level ideologi. Pendekatan yang dilakukan dalam penelitian ini adalah kualitatif interpretatif untuk mendeskripsikan tanda dan lambang dalam video musik tersebut. Diperoleh bahwa representasi kecantikan ditunjukkan melalui fisik (outer beauty) dan kepribadian (inner beauty) yang terlihat dari tanda dan lambang yang terdapat pada video musik menunjukkan adanya: 1) Kecantikan perempuan merupakan produk rekayasa media, 2) Kecantikan perempuan dijadikan sebagai objek komoditas, serta 3) Kecantikan perempuan identik dengan citra kemewahan.
DEVELOPMENT OF SHORT STORY LEARNING LEARNING WITH AMODEL MIND MAPPING IN STUDENTS OF CLASS XI MULTIMEDIA VOCATIONAL SCHOOL OF WIRA BUANA 1 BOGOR
Authors: musaljon
Published: April 2019

Research on the development of learning to write short stories with models mind mapping in students of class XI Multimedia, SMK Wira Buana 1 Bogor needs to be done. This, due to the lack of understanding of students' writing short stories. The method used is research and development(research and development)with a model Borg and Gall. Based on the data analysis, the results of the development study of learning to write short stories using the model mind mapping in students of class XI Multimedia 1 Wira Buana 1 Bogor, (1) stated the validity of the two validators, namely the assessment of the literature expert validator 94% with very good criteria and assessment Indonesian Language and Literature learning validators get a score of 96% with very good criteria (2) stated to have practicality based on the judgment of practitioners (peers) by getting a score of 96% with excellent criteria (3) stated to have effectiveness seen from a small group test at pretest with an average of 67.16% and posttest with an average of 87.16% and standard deviation of 8.51, as well as a large group test at pretest with an average of 67.7% and posttest with an average of 89% and standard deviation of 18.42.
Jurnal_TEDC Vol. 10 No. 3 September 2016
Authors: Marlina Lusi
Published: April 2019

IDENTIFIKASI KANDUNGAN SIKLAMAT PADA MINUMANYANG DIJUAL DI PINGGIR JALAN CIHAMPELASSAMPAI JALAN BATUJAJARLusi Marlina*, Annisa Rani Sa’adah**Program Studi Teknik Kimia, Politeknik TEDC BandungJalan Pasantren Km 2 Cibabat Cimahi Utara 40513Email: lusi@poltektedc.ac.idAbstrakPemanis buatan adalah bahan tambahan makanan yang ditambahkan dalam makanan atau minuman untukmenciptakan rasa manis. Siklamat merupakan jenis pemanis buatan yang memiliki kemanisan 30 kali lebihmanis dari pada sukrosa. Pemakaian pemanis sintetis masih diragukan keamanannya bagi kesehatankonsumen, Beberapa negara mengeluarkan peraturan secara ketat atau bahkan melarang penggunaannya,seperti kanada sejak 1977. Batas Maksimum Penggunaan Siklamat yang diatur dalam ADI (acceptable dailyintake) atau kebutuhan per orang per hari adalah sebanyak 0 – 11 mg per berat badan per hari. Sementarakadar maksimum siklamat dalam minuman 3 gr/L. Untuk mengidentifikasi kandungan siklamat pada minumandapat menggunakan metode gravimetri. metode gravimetri adalah cara analisis kuantitatif berdasarkan berattetap (berat konstannya). Penelitian ini bertujuan untuk mengidentifikasi kandungan siklamat pada minumanyang dijual di pinggir jalan. Dengan mengambil 6 sampel minuman. Pengujian dilakukan di laboratoriumteknik kimia Politeknik TEDC Bandung. Berdasarkan hasil penelitian secara kuantitatif dari 6 sampel seluruhsampel terdeteksi mengandung siklamat, dengan kadar terendah 3 mg dan kadar tertinggi 14,3 mg.Kata kunci: Minuman jajanan, Pemanis Buatan, Siklamat.AbstractAn artificial sweeteners are the food additives that are added to foods or beverages to create a sweet taste.Cyclamate is a kind of artificial sweetener that has a sweetness 30 times sweeter than sucrose. The use ofartificial sweeteners is still questionable safety for the health of consumers, some countries issue regulationsstrictly or even prohibit its use, such as Canada since 1977. Limit Use of Cyclamates set out in the ADI(acceptable daily intake) or requirement per person per day is as much as 0-11 mg per body weight per day.While the maximum levels of cyclamate in drinks 3 g / L. To identify the content of cyclamate in beveragescan using gravimetric methods. gravimetric method is a method of quantitative analysis based on the weightof fixed (constant weight). This study aims to identify the content of cyclamate in drinks sold on the roadside.By taking 6 samples drinks. Tests conducted in the laboratory of chemical engineering TEDC PolytechnicBandung. Based on the results of a quantitative study of 6 samples throughout the sample is detected tocontain cyclamate, with the lowest levels of 3 mg and the highest levels of 14.3 mg.Keywords: Hawker food, An artificial sweeteners, cyclamate
The Ecosystem-Service Values of Italy’s Coastal Dunes
Authors: Open Communications for The Ocean OCTO
Published: April 2019

In this MarXiv Summary audio-edition, we interview Mita Drius about her recent research quantifying the ecosystem services provided by coastal dunes along the Italian Adriatic coast. Her team’s results show that while more people are benefiting from the services provided by these dunes, these same people are putting additional pressures on the habitats. You can read the full-text of these research results in the MarXiv archive.
Association of Comorbid Substance Use Disorders and PTSD on Later Symptom Severity, Functioning, and Economic Outcomes among Veterans Applying for Department of Veterans Affairs PTSD Disability Benefits: A Retrospective Cohort Study
Authors: Boudreaux Michel H , Murdoch Maureen
Published: April 2019

Background: Posttraumatic stress disorder (PTSD) that is comorbid with substance use disorders (SUDs) has been associated with poorer mental health outcomes compared to when SUD is not present. Objectives: To identify the prevalence of SUDs in Veterans who have applied for PTSD disability benefits and, within this subgroup, examine the effect of a SUD diagnosis on PTSD symptom severity, functioning, and economic outcomes approximately 2 years later. Method: Retrospective, gender-stratified cohort study of 4,918 representatively sampled Veterans who applied for Department of Veterans’ Affairs (VA) PTSD disability benefits between 1994 and 1998. We used medical administrative data to determine if a SUD diagnosis was present when Veterans’ disability claims were adjudicated. PTSD symptom severity; work, role, and social functioning; physical functioning; working for pay; and low income were assessed by mailed survey approximately 2 years later. Results: 3,337 (68%) Veterans returned surveys. Among respondents, men were more likely than women to have any SUD diagnosis at the time of their claims’ adjudication (25.6% v. 17.6%, p < 0.001). Regardless of gender, Veterans with a SUD diagnosis had clinically meaningful and statistically significantly severer PTSD symptoms and poorer functioning approximately 2 years after their claim was adjudicated than did Veterans without SUD (ps < 0.001). Work, role, and social functioning was also statistically significantly worse for men and women with a SUD diagnosis (ps < 0.001). In terms of economic outcomes, men and women with a SUD diagnosis at the time their claim was adjudicated were 50-60% less likely to report working for pay two years later and 40%-100% more likely to report low income compared to respondents without a SUD diagnosis (ps < 0.001). Conclusions: Although a substantial fraction of respondents were diagnosed with a SUD at the time their claim was adjudicated, the proportion of men with a SUD was similar to that reported for other clinical samples with PTSD; it was actually lower among the women compared to other clinical samples. A SUD diagnosis was a poor prognostic factor for the Veterans in this sample, associated with severer PTSD, poorer functioning, and poorer economic outcomes.
Clinico-Demographic Profile and Pregnancy Outcome in Placenta Previa: A Study from Tertiary Care Hospital
Authors: Haque Husneyara , Pandit Upendra
Published: April 2019

Introduction: Placenta previa is an obstetric complication which causes considerable maternal and fetal morbidity and mortality during pregnancy. This study is done with the objective to find out the clinico-demographic factors associated with placenta previa and to analyze maternal and perinatal outcome in these cases.

Methods: This was a retrospective study done in the department of Obstetrics and Gynecology of Nepalgunj Medical College Teaching Hospital, Nepalgunj, a tertiary care hospital from Midwestern Nepal. Relevant data were retrieved from maternity register from June 2015 to May 2017. All women who had undergone caesarean section for placenta previa were included in this study.

Result: Out of total 5812 deliveries during the study period there were 50 caesarian sections done for placenta previa which is 0.86% of total deliveries. Maximum number of mothers belonged to 26- 30 years of age group. Commonest type of placenta previa was minor type. About 72% were multiparous. 20% had previous LSCS and 24% had previous abortion. Postpartum hemorrhage was present in 36% mothers and 32% received blood transfusion. About 64% new born were preterm and low birth weight. 34% babies had less than 7 apgar score at 5 min. Still births were 6%.

Conclusion: Placenta previa poses greater risk and need of blood transfusion to mother as well as birth of preterm and low birth weight babies which leads to perinatal morbidity and mortality. Timely diagnosis, regular antenatal check up and effective management may improve pregnancy outcome.
Prevalence and Risk Factors Associated with Anaemia Amongst Adolescent Girls Attending in Pediatrics OPD of Nepalgunj Medical College
Authors: Ahmad Shakil
Published: April 2019

Background: The habits that children inculcate during adolescence remains with them throughout the life. Anaemia is one of the most prevalent health conditions amongst the Girls residing in developing countries. The present study was conducted with the aim to determine the prevalence and risk factors associated with anaemia amongst adolescent girls attending in paediatrics OPD of Nepalgunj Medical College.

Materials and methods: The present cross sectional study was performed for a period of one year (February 2016 - March 2017). This study was conducted amongst the girls attending to the Paediatrics department of Nepalgunj Medical College and Teaching Hospital, Nepalgunj. The study included all the girls aged between 10-19 years. Each Girls underwent physical examination under trained supervision to record sign of anaemia like pallor. Body mass index of all the subjects was also calculated. The data obtained was arranged in a tabulated form and analysed using SPSS software.

Results: A total of 200 girls were enrolled in this study. The mean age of the study sample was 21.10+/-10.67 years. Majority of the early adolescents (68.5%) had anaemia. Least number (36%) of anaemic patients was seen in mid adolescence. There were 47.5% girls in late adolescence that showed signs of anaemia. There were 47.9% Girls who had passage of worms and 50.1% had no worm infestations. Majority (63.5%) of non anaemic Girls were in their post menarche stage.

Conclusion: There were 52% of the girls who were anaemic in our study. The proportion of undernourished girls were significantly higher, therefore body mass index significantly affects anaemia.
DIRECTIONS OF THE BALANCED DEVELOPMENT OF THE UKRAINIAN TRANSPORT SYSTEM IN CONDITIONS OF THE MARKET OF TRANSPORT SERVICES GLOBALIZATION
Authors: Lavrushchenko Yu.O.
Published: April 2019

Topicality. The relevance of a problem of development of world economic communications, an advantageous geopolitical position of Ukraine which is on crossing of the major trade ways reveals economic prerequisites and regional aspects of creation of logistics transport and distributive systems when forming strategy of service of transport freight traffics through the territory of Ukraine.Also tendencies of development of world economic communications predetermine expansion of production communications and the international economic cooperation. However the uneven constant growth of transnational and transborder streams and the international transit predetermines new tasks and problems of management of commodity and cash flows.Aim and tasks. Among the priority directions of transport policy, along with development of technical means of transport, need of updating of its fixed assets at qualitatively new level, introductions of new progressive technologies, informatization of transportation process, problems of ensuring coordination of activity of different types of transport, development of intermodal transportation of goods in the international transport corridors, the complex solution of regional transport tasks are allocated, to integration of the Ukrainian market of transport services into the world transport system.Research results.The major theoretical and practical task is creation of system of integrated management of balance of interests and efficiency of functioning of the integrated transport systems.It is necessary to pay attention to basic value for the integrated aspirations of Ukraine in a sea economic complex. The role of a sea economic complex of Ukraine is not realized sufficiently therefore the target national program of stability of functioning of merchant marine fleet, seaports, ship-building base and service divisions of a complex is not developed. Control of sustainable development of a transport component of a sea economic complex has to be exercised according to the method given (formula 1). Then parameters of stability of a sea transport complex have to be regulated on the basis of the principle of sufficiency of potential by macroeconomic results.Conclusions. Participation of the national fleet and ports in development of integration processes on transport in the conditions of globalization of world economy has to be based on organizational and economic prerequisites of formation and development of the integrated transport and distributive systems at the regional, interregional and international levels.
Improved survival of glioblastoma patients treated at academic and high-volume facilities: a hospital-based study from the National Cancer Database
Authors: Zhu Ping , Du Xianglin L. , Zhu Jay-Jiguang , Esquenazi Yoshua
Published: April 2019

OBJECTIVE

The present study was designed to explore the association between facility type (academic center [AC] vs non-AC), facility volume (high-volume facility [HVF] vs low-volume facility [LVF]), and outcomes of glioblastoma (GBM) treatment.

METHODS

Based on the National Cancer Database (NCDB), GBM patients were categorized by treatment facility type (non-AC vs AC) and volume [4 categories (G1–G4): < 5.0, 5.0–14.9, 15.0–24.9, and ≥ 25.0, cases/year]. HVF was defined based on the 90th percentile of annual GBM cases (≥ 15.0 cases/year). Outcomes include overall survival (OS), the receipt of surgery and adjuvant therapies, 30-day readmission/mortality, 90-day mortality, and prolonged length of inpatient hospital stay (LOS). Kaplan-Meier methods and accelerated failure time (AFT) models were applied for survival analysis, and multivariable logistic regression models were performed to compare differences in the receipt of treatment and related short-term outcomes by facility type and volume.

RESULTS

A total of 40,256 GBM patients diagnosed between 2004 and 2014 were included. Patients treated at an AC & HVF experienced the longest survival (median OS: 13.3, 11.8, 11.1, and 10.3 months; time ratio [TR]: 1.00 [Ref.], 0.96, 0.92, and 0.89; for AC & HVF, AC & LVF, non-AC & HVF, and non-AC & LVF, respectively), regardless of care transition/treatment referral. Tumor resection, radiotherapy, and chemotherapy were most frequently utilized in AC & HVF. Prolonged LOS, 30-day readmission, and 90-day mortality were decreased by 20%, 22%, and 16% (p ≤ 0.001), respectively, at AC & HVF.

CONCLUSIONS

This study provides evidence of superior outcomes when GBM patients are treated at AC and HVF. Standardization of health care across facility type and/or volume and comprehensive neuro-oncological care should be a potential goal in the management of GBM patients.
Pilot project to assess and improve neurosurgery resident and staff perception of feedback to residents for self-improvement goal formation
Authors: Tenny Steven O. , Schmidt Kyle P. , Thorell William E.
Published: April 2019

OBJECTIVE

The Accreditation Council for Graduate Medical Education (ACGME) has pushed for more frequent and comprehensive feedback for residents during their training, but there is scant evidence for how neurosurgery residents view the current feedback system as it applies to providing information for self-improvement and goal formation. The authors sought to assess neurosurgery resident and staff perceptions of the current resident feedback system in providing specific, meaningful, achievable, realistic, and timely (SMART) goals. The authors then created a pilot project to improve the most unfavorably viewed aspect of the feedback system.

METHODS

The authors conducted an anonymous survey of neurosurgery residents and staff at an academic medical institution to assess SMART goals for resident feedback and used the results to create a pilot intervention to address the most unfavorably viewed aspect of the feedback system. The authors then conducted a postintervention survey to see if perceptions had improved for the target of the intervention.

RESULTS

Neurosurgery residents and staff completed an anonymous online survey, for which the results indicated that resident feedback was not occurring in a timely manner. The authors created a simple anonymous feedback form. The form was distributed monthly to neurosurgery residents, neurosurgical staff, and nurses, and the results were reported monthly to each resident for 6 months. A postintervention survey was then administered, and the results indicated that the opinions of the neurosurgery residents and staff on the timeliness of resident feedback had changed from a negative to a nonnegative opinion (p = 0.01).

CONCLUSIONS

The required ACGME feedback methods may not be providing adequate feedback for goal formation for self-improvement for neurosurgery residents. Simple interventions, such as anonymous feedback questionnaires, can improve neurosurgery resident and staff perception of feedback to residents for self-improvement and goal formation.
Primary intracranial malignant melanoma: proposed treatment protocol and overall survival in a single-institution series of 15 cases combined with 100 cases from the literature
Authors: Li Cheng-Bei , Song Lai-Rong , Li Da , Weng Jian-Cong , Zhang Li-Wei , Zhang Jun-Ting , Wu Zhen
Published: April 2019

OBJECTIVE

The overall survival and pertinent adverse factors for primary intracranial malignant melanoma (PIMM) have not been previously determined. This aim of this study was to determine the rates of progression-free survival (PFS) and overall survival (OS) and identify the adverse factors for PIMM.

METHODS

This study included 15 cases from the authors’ own series and 100 cases with detailed clinical data that were obtained from the literature from 1914 to 2018 using the Ovid Medline, EMBASE, PubMed, Cochrane, and EBSCO databases. Patient demographics, treatment (surgery, chemotherapy, and radiotherapy [RT]), PFS, and OS were reviewed. Data from prior publications were processed and used according to PRISMA guidelines.

RESULTS

Diffuse lesions were identified in 24 (20.9%) patients, who had a younger age (p < 0.001). The mean follow-up time was 16.6 months, and 76 (66.1%) deaths occurred. The 6-month, 1-year, 3-year, and 5-year OS rates of the whole cohort were 62.8%, 49.9%, 28.9%, and 17.2%, respectively, with an estimated median survival time (EMST) of 12.0 months. The multivariate analysis revealed that gross-total resection (GTR) (HR 0.299, 95% CI 0.180–0.497, p < 0.001), radiotherapy (HR 0.577, 95% CI 0.359–0.929, p = 0.024), and chemotherapy (HR 0.420, 95% CI 0.240–0.735, p = 0.002) predicted a better OS. The EMST was 5.0 months in patients with diffuse-type PIMM and 13.0 months in patients with the solitary type. Patients receiving GTR with adjuvant RT and/or chemotherapy (GTR + [RT and/or chemo]) had significantly higher 1-year and 5-year OS rates (73.0% and 40.1%, respectively) and a longer EMST (53 months) than patients who underwent GTR alone (20.5 months) or RT and/or chemotherapy without GTR (13.0 months).

CONCLUSIONS

Optimal outcomes could be achieved by radical resection plus postoperative radiotherapy and/or chemotherapy. Patients with diffuse PIMM have a more severe clinical spectrum and poorer survival than patients with solitary PIMM. Immunotherapy and targeted therapy show promise as treatment options for PIMM based on results in patients with brain metastases from extracranial melanoma.
SF-36 scores predict postoperative delirium after surgery for cervical spondylotic myelopathy
Authors: Kin Kyohei , Yasuhara Takao , Tomita Yousuke , Umakoshi Michiari , Morimoto Jun , Date Isao
Published: April 2019

OBJECTIVE

Cervical spondylotic myelopathy (CSM) is one of the most common causes of spinal cord dysfunction. Surgery for CSM is generally effective, but postoperative delirium is a potential complication. Although there have been some studies that investigated postoperative delirium after spine surgery, no useful tool for identifying high-risk patients has been established, and it is unknown if 36-Item Short Form Health Survey (SF-36) scores can predict postoperative delirium. The objective of this study was to evaluate the correlation between preoperative SF-36 scores and postoperative delirium after surgery for CSM.

METHODS

Sixty-seven patients who underwent surgery for CSM at the authors’ institution were enrolled in this study. Medical records of these patients were retrospectively reviewed. Patient background, preoperative laboratory data, preoperative SF-36 scores, the preoperative Japanese Orthopaedic Association (JOA) score for the evaluation of cervical myelopathy, and perioperative factors were selected as potential risk factors for postoperative delirium. These factors were evaluated using univariable and multivariable logistic regression analysis.

RESULTS

Ten patients were diagnosed with postoperative delirium. Univariable analysis revealed that the physical functioning score (p = 0.01), general health perception score (p < 0.01), and vitality score (p < 0.01) of the SF-36 were significantly lower in patients with postoperative delirium than in those without. The total number of medications was significantly higher in the delirium group compared with the no-delirium group (p = 0.02). In contrast, there were no significant differences between the delirium group and the no-delirium group in cervical JOA scores (p = 0.20). Multivariable analysis revealed that a low general health perception score was an independent risk factor for postoperative delirium (p = 0.02; odds ratio 0.810, 95% confidence interval 0.684–0.960).

CONCLUSIONS

Some of the SF-36 scores were significantly lower in patients with postoperative delirium than in those without. In particular, the general health perception score was independently correlated with postoperative delirium. SF-36 scores could help identify patients at high risk for postoperative delirium and aid in the development of prevention strategies.
Cortical spreading depolarizations induced by surgical field blood in a mouse model of neurosurgery
Authors: Srienc Anja I. , Chiang Pei-Pei , Schmitt Abby J. , Newman Eric A.
Published: April 2019

OBJECTIVE

Cortical spreading depolarization (CSD) has been linked to poor clinical outcomes in the setting of traumatic brain injury, malignant stroke, and subarachnoid hemorrhage. There is evidence that electrocautery during neurosurgical procedures can also evoke CSD waves in the brain. It is unknown whether blood contacting the cortical surface during surgical bleeding affects the frequency of spontaneous or surgery-induced CSDs. Using a mouse neurosurgical model, the authors tested the hypothesis that electrocautery can induce CSD waves and that surgical field blood (SFB) is associated with more CSDs. The authors also investigated whether CSD can be reliably observed by monitoring the fluorescence of GCaMP6f expressed in neurons.

METHODS

CSD waves were monitored by using confocal microscopy to detect fluorescence increases at the cortical surface in mice expressing GCaMP6f in CamKII-positive neurons. The cortical surface was electrocauterized through an adjacent burr hole. SFB was simulated by applying a drop of tail vein blood to the brain through the same burr hole.

RESULTS

CSD waves were readily detected in GCaMP6f-expressing mice. Monitoring GCaMP6f fluorescence provided far better sensitivity and spatial resolution than detecting CSD events by observing changes in the intrinsic optical signal (IOS). Forty-nine percent of the CSD waves identified by GCaMP6f had no corresponding IOS signal. Electrocautery evoked CSD waves. On average, 0.67 ± 0.08 CSD events were generated per electrocautery episode, and multiple CSD waves could be induced in the same mouse by repeated cauterization (average, 7.9 ± 1.3 events; maximum number in 1 animal, 13 events). In the presence of SFB, significantly more spontaneous CSDs were generated (1.35 ± 0.37 vs 0.13 ± 0.16 events per hour, p = 0.002). Ketamine effectively decreased the frequency of spontaneous CSD waves (1.35 ± 0.37 to 0.36 ± 0.15 CSD waves per hour, p = 0.016) and electrocautery-stimulated CSD waves (0.80 ± 0.05 to 0.18 ± 0.08 CSD waves per electrocautery, p = 0.00002).

CONCLUSIONS

CSD waves are detected with far greater sensitivity and fidelity by monitoring GCaMP6f signals in neurons than by monitoring IOSs. Electrocautery reliably evokes CSD waves, and the frequency of spontaneous CSD waves is increased when blood is applied to the cortical surface. These experimental conditions recapitulate common scenarios in the neurosurgical operating room. Ketamine, a clinically available pharmaceutical agent, can block stimulated and spontaneous CSDs. More research is required to understand the clinical importance of intraoperative CSD.
Travels to the tropics: Deutschtum and Fedor Krause’s visits to Brazil
Authors: Figueiredo Eberval Gadelha , Almeida da Silva Saul , Jacobsen Teixeira Manoel , Belykh Evgenii , Carotenuto Alessandro , Moreira Leandro Borba , Spetzler Robert F. , Dagi T. Forcht , Preul Mark C.
Published: April 2019

Fedor Krause, the father of German neurosurgery, traveled to Latin America twice in the final years of his career (in 1920 and 1922). The associations and motivations for his travels to South America and his work there have not been well chronicled. In this paper, based on a review of historical official documents and publications, the authors describe Krause’s activities in South America (focusing on Brazil) within the context of the Germanism doctrine and, most importantly, the professional enjoyment Krause reaped from his trips as well as his lasting influence on neurosurgery in South America. Fedor Krause’s visits to Brazil occurred soon after World War I, when Germany sought to reestablish economic, political, cultural, and scientific power and influence. Science, particularly medicine, had been chosen as a field capable of meeting these needs. The advanced German system of academic organization and instruction, which included connections and collaborations with industry, was an optimal means to reestablish the economic viability of not only Germany but also Brazil. Krause, as a de facto ambassador, helped rebuild the German image and reconstruct diplomatic relations between Germany and Brazil. Krause’s interactions during his visits helped put Brazilian neurosurgery on a firm foundation, and he left an indelible legacy of advancing professionalism and specialization in neurosurgery in Brazil.
Relationship between middle cerebral parent artery asymmetry and middle cerebral artery aneurysm rupture risk factors
Authors: Duan Yifei , Lagman Carlito , Ems Raleigh , Bambakidis Nicholas C.
Published: April 2019

OBJECTIVE

The exact pathophysiological mechanisms underlying cerebral aneurysm formation remain unclear. Asymmetrical local vascular geometry may play a role in aneurysm formation and progression. The object of this study was to investigate the association between the geometric asymmetry of the middle cerebral artery (MCA) and the presence of MCA aneurysms and associated high-risk features.

METHODS

Using a retrospective case-control study design, the authors examined MCA anatomy in all patients who had been diagnosed with an MCA aneurysm in the period from 2008 to 2017 at the University Hospitals Cleveland Medical Center. Geometric features of the MCA ipsilateral to MCA aneurysms were compared with those of the unaffected contralateral side (secondary control group). Then, MCA geometry was compared between patients with MCA aneurysms and patients who had undergone CTA for suspected vascular pathology but were ultimately found to have normal intracranial vasculature (primary control group). Parent vessel and aneurysm morphological parameters were measured, calculated, and compared between case and control groups. Associations between geometric parameters and high-risk aneurysm features were identified.

RESULTS

The authors included 247 patients (158 cases and 89 controls) in the study. The aneurysm study group consisted of significantly more women and smokers than the primary control group. Patients with MCA bifurcation aneurysms had lower parent artery inflow angles (p = 0.01), lower parent artery tortuosity (p < 0.01), longer parent artery total length (p = 0.03), and a significantly greater length difference between ipsilateral and contralateral prebifurcation MCAs (p < 0.01) than those in primary controls. Type 2 MCA aneurysms (n = 89) were more likely to be associated with dome irregularity or a daughter sac and were more likely to have a higher cumulative total of high-risk features than type 1 MCA aneurysms (n = 69).

CONCLUSIONS

Data in this study demonstrated that a greater degree of parent artery asymmetry for MCA aneurysms is associated with high-risk features. The authors also found that the presence of a long and less tortuous parent artery upstream of an MCA aneurysm is a common phenotype that is associated with a higher risk profile. The aneurysm parameters are easily measurable and are novel radiographic biomarkers for aneurysm risk assessment.
Postoperative structured rehabilitation in patients undergoing surgery for cervical radiculopathy: a 2-year follow-up of a randomized controlled trial
Authors: Peolsson Anneli , Löfgren Håkan , Dedering Åsa , Öberg Birgitta , Zsigmond Peter , Hedevik Henrik , Wibault Johanna
Published: April 2019

OBJECTIVE

Information about postoperative rehabilitation for cervical radiculopathy (CR) is scarce. The aim of this study was to investigate the additional benefits of structured postoperative rehabilitation (SPT), which was performed in all patients, compared with a pragmatic standard postoperative approach (SA), in which rehabilitation was used as needed and patients sought physiotherapy on their own without a referral, in patients with MRI evidence of disc herniation and concomitant clinical signs who underwent surgery for CR.

METHODS

Patients (n = 202) were randomized to receive SPT or SA. Included key variables in the present study were primary and selected secondary outcomes of a prospective randomized controlled multicenter study. The main outcome was the Neck Disability Index (NDI) score. The NDI score, pain variables, self-efficacy, and health-related quality of life were investigated at baseline and 3, 6, 12, and 24 months postoperatively.

RESULTS

SPT provided no additional benefits over SA (p = 0.08 to p = 0.99) at the postoperative 2-year follow-up. Both groups improved over time (p < 0.0001), with no reported adverse effects.

CONCLUSIONS

One can conclude that SPT offered no additional benefits over SA; however, patients tolerated postoperative neck exercises without any negative side effects. These findings are important for the development of future active and neck-specific postoperative rehabilitation interventions for patients with CR.

Clinical trial registration no.: NCT01547611 (clinicaltrials.gov)
Reconstruction of the spinal accessory nerve with selective fascicular nerve transfer of the upper trunk
Authors: Mayer Johannes A. , Hruby Laura A. , Salminger Stefan , Bodner Gerd , Aszmann Oskar C.
Published: April 2019

OBJECTIVE

Spinal accessory nerve palsy is frequently caused by iatrogenic damage during neck surgery in the posterior triangle of the neck. Due to late presentation, treatment regularly necessitates nerve grafts, which often results in a poor outcome of trapezius function due to long regeneration distances. Here, the authors report a distal nerve transfer using fascicles of the upper trunk related to axillary nerve function for reinnervation of the trapezius muscle.

METHODS

Five cases are presented in which accessory nerve lesions were reconstructed using selective fascicular nerve transfers from the upper trunk of the brachial plexus. Outcomes were assessed at 20 ± 6 months (mean ± SD) after surgery, and active range of motion and pain levels using the visual analog scale were documented.

RESULTS

All 5 patients regained good to excellent trapezius function (3 patients had grade M5, 2 patients had grade M4). The mean active range of motion in shoulder abduction improved from 55° ± 18° before to 151° ± 37° after nerve reconstruction. In all patients, unrestricted shoulder arm movement was restored with loss of scapular winging when abducting the arm. Average pain levels decreased from 6.8 to 0.8 on the visual analog scale and subsided in 4 of 5 patients.

CONCLUSIONS

Restoration of spinal accessory nerve function with selective fascicle transfers related to axillary nerve function from the upper trunk of the brachial plexus is a good and intuitive option for patients who do not qualify for primary nerve repair or present with a spontaneous idiopathic palsy. This concept circumvents the problem of long regeneration distances with direct nerve repair and has the advantage of cognitive synergy to the target function of shoulder movement.
Opioid-free anesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: a retrospective matched cohort study
Authors: Soffin Ellen M. , Wetmore Douglas S. , Beckman James D. , Sheha Evan D. , Vaishnav Avani S. , Albert Todd J. , Gang Catherine H. , Qureshi Sheeraz A.
Published: April 2019

OBJECTIVE

Enhanced recovery after surgery (ERAS) and multimodal analgesia are established care models that minimize perioperative opioid consumption and promote positive outcomes after spine surgery. Opioid-free anesthesia (OFA) is an emerging technique that may achieve similar goals. The purpose of this study was to evaluate an OFA regimen within an ERAS pathway for lumbar decompressive surgery and to compare perioperative opioid requirements in a matched cohort of patients managed with traditional opioid-containing anesthesia (OCA).

METHODS

The authors performed a retrospective analysis of prospectively collected data. They included 36 patients who underwent lumbar decompression under their ERAS pathway for spinal decompression between February and August 2018. Eighteen patients who received OFA were matched in a 1:1 ratio to a cohort managed with a traditional OCA regimen. The primary outcome was total perioperative opioid consumption. Postoperative pain scores (measured using the numerical rating scale [NRS]), opioid consumption (total morphine equivalents), and length of stay (time to readiness for discharge) were compared in the postanesthesia care unit (PACU). The authors also assessed compliance with ERAS process measures and compared compliance during 3 phases of care: pre-, intra-, and postoperative.

RESULTS

There was a significant reduction in total perioperative opioid consumption in patients who received OFA (2.43 ± 0.86 oral morphine equivalents [OMEs]; mean ± SEM), compared to patients who received OCA (38.125 ± 6.11 OMEs). There were no significant differences in worst postoperative pain scores (NRS scores 2.55 ± 0.70 vs 2.58 ± 0.73) or opioid consumption (5.28 ± 1.7 vs 4.86 ± 1.5 OMEs) in the PACU between OFA and OCA groups, respectively. There was a clinically significant decrease in time to readiness for discharge from the PACU associated with OFA (37 minutes), although this was not statistically significantly different. The authors found high overall compliance with ERAS process measures (91.4%) but variation in compliance according to phase of care. The highest compliance occurred during the preoperative phase (94.71% ± 2.88%), and the lowest compliance occurred during the postoperative phase of care (85.4% ± 5.7%).

CONCLUSIONS

OFA within an ERAS pathway for lumbar spinal decompression represents an opportunity to minimize perioperative opioid exposure without adversely affecting pain control or recovery. This study reveals opportunities for patient and provider education to reinforce ERAS and highlights the postoperative phase of care as a time when resources should be focused to increase ERAS adherence.
Characterizing the risk and outcome profiles of lumbar fusion procedures in patients with opioid use disorders: a step toward improving enhanced recovery protocols for a unique patient population
Authors: Martini Michael L. , Nistal Dominic A. , Deutsch Brian C. , Caridi John M.
Published: April 2019

OBJECTIVE

The authors set out to conduct the first national-level study assessing the risks and outcomes for different lumbar fusion procedures in patients with opioid use disorders (OUDs) to help guide the future development of targeted enhanced recovery after surgery (ERAS) protocols for this unique population.

METHODS

Data for patients with or without OUDs who underwent an anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF), or lateral transverse lumbar interbody fusion (LLIF) for lumbar disc degeneration (LDD) were collected from the 2013–2014 National (Nationwide) Inpatient Sample database. Multivariable logistic regression was implemented to analyze how OUD status impacted in-hospital complications, length of hospital stay, discharge disposition, and total charges by procedure type.

RESULTS

A total of 139,995 patients with LDD were identified, with 1280 patients (0.91%) also having a concurrent OUD diagnosis. Overall complication rates were higher in OUD patients (48.44% vs 31.01%, p < 0.0001). OUD patients had higher odds of pulmonary (p = 0.0006), infectious (p < 0.0001), and hematological (p = 0.0009) complications. Multivariate regression modeling of outcomes by procedure type showed that after ALIF, OUD patients had higher odds of nonhome discharge (p = 0.0007), extended hospitalization (p = 0.0002), and greater total charges (p = 0.0054). This analysis also revealed that OUD patients faced higher odds of complication (p = 0.0149 and p = 0.0471), extended hospitalization (p = 0.0439 and p = 0.0001), and higher total charges (p < 0.0001 and p < 0.0001) after PLIF and LLIF procedures, respectively.

CONCLUSIONS

Obtaining a better understanding of the risks and outcomes that OUD patients face perioperatively is a necessary step toward developing more effective ERAS protocols for this vulnerable population. This study, which sought to characterize the outcome profiles for lumbar fusion procedures in OUD patients on a national level, found that this population tended to experience increased odds of complications, extended hospitalization, nonhome discharge, and higher total costs. Results from this study warrant future prospective studies to better the understanding of these associations and to further the development of better ERAS programs that may improve patient care and reduce cost burden.