bluuebunny/crossref_metadata_2025 huggingface dataset:
Task-based language teaching
Authors: Vandommele Goedele , Van den Branden Kris , Van Gorp Koen
Published: September 2018

The purpose of the study described in this chapter was to explore the classroom practices of teachers with varying degrees of experience in task-based language teaching (TBLT) while using a task-based syllabus. In particular, we wanted to assess the extent to which their actual classroom practices are in line with the main tenets of the task-based approach. We observed four teachers as they were team teaching in pairs during a two-week summer school for adolescent newcomers with high-beginner proficiency levels of Dutch. Results indicate that the classroom practices of both teaching teams lived up to the main principles of TBLT. On the whole, the classroom practice of the more experienced team of teachers was systematically rated higher. The classroom practice of the inexperienced team was found to be consistent with three out of the five principles that were rated, namely “Promote Learning by Doing”, “Focus on Form” and “Provide Input and Opportunities to Produce Output”. However, two other principles (“Provide Negative Feedback” and “Individualize Instruction”) were virtually absent in teachers’ use of tasks. The experienced team was found to implement some of the principles during all activities, while others seemed much more context-dependent. This study may deepen our insight into the different features of TBLT, in particular regarding core and more peripheral features of TBLT. Ultimately, it can guide qualitative training of teachers new to TBLT.
The Rouge River Area of Concern - A multi-year, multi-level successful approach to restoration of Impaired Beneficial Uses
Authors: Ridgway J. , Cave K. , DeMaria A. , O’Meara J. , Hartig J. H.
Published: September 2018

Citizen outcry in the 1960s led to passage of the 1972 U.S. Clean Water Act. Expansion of industrial permitting and availability of federal grants to municipalities controlled industrial waste and untreated municipal sewage entering the Rouge River. However, many sources persisted – notably wet weather discharges, stormwater runoff, and contaminated sediments. This remaining pollution led state officials to cooperatively craft the Rouge River Remedial Action Plan in 1985. This plan addressed all pollution sources, but was not substantially implemented until 1993 when the federal government, encouraged by Congressmen Dingell and Knollenberg, committed to the Rouge River National Wet Weather Demonstration Project. The federal government ultimately delivered $350 million that was matched by $700 million in local funds. Efforts have been sustained through multi-year state and federal grants, with additional funding from local communities and other stakeholders. Early focus of the Rouge Project was on untreated sewage from combined sewer overflows, but quickly expanded to address other impairments from sanitary sewer overflows, stormwater runoff, illicit connections and failing septic systems. With major sewage discharges under control, efforts shifted to remediating contaminated sediments and improving in-stream water quality and habitat. In total, over 380 projects were completed by 75 communities and agencies at a cost of over $1 billion since 1988, resulting in improved water, sediment, and biological quality. Prior to the U.S. Clean Water Act, the Rouge River nearly continuously failed to meet water quality standards. After decades of effort and investment, it now rarely violates standards. This miraculous recovery was initiated by a small handful of citizens, facilitated by local municipal leaders, and supported by the federal government. The Rouge River is a model for how a holistic, ecosystem approach to water pollution can result in cost-effective and greater and faster achievement of restoration, while meeting local needs.
A Xenopus oocyte model system to study action potentials
Authors: Corbin-Leftwich Aaron , Small Hannah E. , Robinson Helen H. , Villalba-Galea Carlos A. , Boland Linda M.
Published: September 2018

Action potentials (APs) are the functional units of fast electrical signaling in excitable cells. The upstroke and downstroke of an AP is generated by the competing and asynchronous action of Na+- and K+-selective voltage-gated conductances. Although a mixture of voltage-gated channels has been long recognized to contribute to the generation and temporal characteristics of the AP, understanding how each of these proteins function and are regulated during electrical signaling remains the subject of intense research. AP properties vary among different cellular types because of the expression diversity, subcellular location, and modulation of ion channels. These complexities, in addition to the functional coupling of these proteins by membrane potential, make it challenging to understand the roles of different channels in initiating and “temporally shaping” the AP. Here, to address this problem, we focus our efforts on finding conditions that allow reliable AP recordings from Xenopus laevis oocytes coexpressing Na+ and K+ channels. As a proof of principle, we show how the expression of a variety of K+ channel subtypes can modulate excitability in this minimal model system. This approach raises the prospect of studies on the modulation of APs by pharmacological or biological means with a controlled background of Na+ and K+ channel expression.
Parent Instrumentality for Adolescent Eating and Activity
Authors: Orehek Edward , Ferrer Rebecca
Published: September 2018

Background

Parent–adolescent interactions have health implications for adolescents. Parents can be instrumental to healthy eating by purchasing fruits and vegetables or refraining from purchasing hedonic (low nutrient, high energy-dense) foods. Parents can be instrumental to healthy activity by modeling exercise behavior or discouraging sedentary activities.

Purpose

This research leverages theory on goal pursuit within relationships to investigate whether parents are instrumental to adolescents’ eating and activity.

Methods

Using a national sample of 1,556 parent–adolescent dyads, we conducted dyadic analyses to examine whether parent instrumentality (both parent-perceived and adolescent-perceived) for healthy behaviors was associated with adolescent engagement in those behaviors. We examined whether the link between parent instrumentality and adolescent BMI was mediated by parent instrumentality. We also explored whether parent instrumentality was associated with parent behaviors and parent BMI.

Results

Greater adolescent-perceived parent instrumentality was associated with greater fruit and vegetable consumption and physical activity, and lower sedentariness. Parent-perceived parent instrumentality was associated with greater adolescent fruit and vegetable consumption, less hedonic eating, and more activity. Mediation modeling suggests that adolescent BMI is partially attributable to parent instrumentality for activity. Instrumental parents also engage in healthier behaviors, some of which in turn are associated with lower parent BMI.

Conclusions

Findings have implications for the promotion of healthy eating and activity patterns among adolescents. Parental instrumentality for behavior may be an important target for interventions to improve adolescent health, and interventions may be most successful in facilitating adolescent behavior change if they target both parent- and adolescent-perceived parent instrumentality.
Xanthine Oxidase Inhibitor, Febuxostat Ameliorates the High Salt Intake–Induced Cardiac Hypertrophy and Fibrosis in Dahl Salt-Sensitive Rats
Authors: Namai-Takahashi Asako , Sakuyama Akihiro , Nakamura Takahiro , Miura Takahiro , Takahashi Junta , Kurosawa Ryo , Kohzuki Masahiro , Ito Osamu
Published: September 2018

BACKGROUND

Xanthine oxidase (XO) is a source of reactive oxygen species production in the heart. However, pathophysiological role of XO has not been clarified in hypertensive heart disease. Thus, the present study examined the impacts of high salt (HS) intake and febuxostat (Fx), a XO inhibitor in Dahl salt-sensitive (Dahl-S) rats.

METHODS

Eight-week old, male Dahl-S rats were fed a normal salt diet (0.6% NaCl) or a HS diet (8% NaCl) for 8 weeks. A part of the rats fed the HS diet were simultaneously treated with Fx (3 mg/kg/day).

RESULTS

HS intake increased blood pressure and heart weight with cardiomyocyte hypertrophy and interstitial fibrosis in the left ventricle (LV), and Fx diminished them. HS increased the XO activity 4.7-fold and nicotinamide-adenine dinucleotide phosphate (NADPH) oxidase activity 1.5-fold, and Fx not only blocked the XO activity but also inhibited the HS-increased NADPH oxidase activity. HS increased the expression of XO, collagen, transforming growth factor-β1 (TGF-β1), angiotensin-converting enzyme, and angiotensin II type 1 receptor and the phosphorylation of extracellular signal-regulated kinase (ERK) in the LV, and Fx reduced the expression and phosphorylation of these proteins except XO.

CONCLUSIONS

Fx ameliorates the HS intake-induced hypertension, LV hypertrophy, and fibrosis with decreasing the TGF-β1 expression and ERK phosphorylation in Dahl-S rats. Fx also down-regulates cardiac NADPH oxidase and renin–angiotensin system. The XO inhibition may be an effective therapy for hypertensive heart disease.
Sedimentary basin investigation using receiver function: an East African Rift case study
Authors: Piana Agostinetti Nicola , Martini Francesca , Mongan Joe
Published: September 2018

We apply receiver function (RF) methodology to map the geometry of a sedimentary basin along a ∼10-km-long profile of broadband seismometers that recorded continuously for approximately 3 months. For a subset of the stations, we apply the Neighbourhood Algorithm inversion scheme, to quantify the geometry of basin bounding fault directly beneath the stations. We compare our results with active reflection seismic data and with the lithostratigraphy from a well located along the profile. We find that the  P-to-s conversions from the sediments–basement interface (SBI), recorded in RF data sets together with information on intrabasin structures, are useful for obtaining high resolution images of the basin. The depth of the SBI derived from RF inversion is consistent (within ∼0.4 km) with the estimates from active reflection seismic and the well data. This study highlights that analysis of teleseismic waveforms can retrieve relevant information on the structure of a sedimentary basin.
8. Freedom of assembly and association
Authors: Rainey Bernadette
Published: September 2018

Each Concentrate revision guide is packed with essential information, key cases, revision tips, exam Q&As, and more. Concentrates show you what to expect in a law exam, what examiners are looking for, and how to achieve extra marks. This chapter focuses on freedom of assembly and association, which is dealt with together in Article 11 of the European Convention on Human Rights (ECHR) but separately in the International Covenant on Civil and Political Rights (ICCPR). It looks at the various forms of an assembly, and considers forms of association such as political parties, other interest groups, and trade unions, and how a state must justify any restriction on Article 11(1) given the extremely narrow margin of appreciation when it comes to political parties. The chapter also discusses public order and protest that has led to litigation in England and Wales to determine what is meant by imminent breach of the peace, the limits on processions and assembly, and the proportionality of state measures under Article 11 (with Articles 10 and 5).
2. Supremacy, direct effect, indirect effect, and state liability
Authors: Homewood Matthew J.
Published: September 2018

This chapter discusses the key concepts within the EU legal order: supremacy, direct effect, indirect effect, and state liability. The doctrine of supremacy dictates that EU law takes precedence over conflicting provisions of national law. If a provision of EU law is directly effective, it gives rise to rights upon which individuals can rely directly in the national court. If an EU measure is not directly effective, a claimant may be able to rely on it through the application of indirect effect, which requires national law to be interpreted in accordance with relevant EU law. State liability gives rise to a right to damages where an individual has suffered loss because a Member State has failed to implement a directive or has committed other breaches of EU law.
9. Mixed Questions
Authors: Allen Mischa
Published: September 2018

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, diagram answer plans, suggested answers, author commentary and advice on study skills. This chapter presents sample exam questions on mixed topics. The styles adopted for criminal law examination questions can vary enormously. Some examiners will set problem questions that focus largely on one area, others will set mixed questions which cut right across the syllabus. A mixed question requires knowledge of a wide variety of often unrelated topics. There are some classic combinations such as sexual offences and offences against the person or murder/manslaughter, but candidates should be aware that some topics, such as defences and actus reus and mens rea are pervasive. Mixed questions will generally be of two types: (1) where candidates have to cover a vast number of issues briefly; (2) where candidates need to cover some issues briefly, but others in some depth. This chapter presents examples of mixed questions and suggested answers. Some typical areas for combination are presented.
6. The Free Movement of Goods
Authors: Foster Nigel
Published: September 2018

The Concentrate Questions and Answers series offer the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary, and illustrative diagrams and flowcharts. This chapter presents sample exam questions along with examiner’s tips, answer plans, and suggested answers about the free movement of goods in the EU. The questions focus on charges and measures having equivalent effect, the restrictions allowed under Art 36 TFEU, and the principles of law which have emerged from the case of Cassis de Dijon and subsequent cases. The significance of the judgment of the Court of Justice in Keck is addressed.
9. Sex Discrimination and Equality Law
Authors: Foster Nigel
Published: September 2018

The Concentrate Questions and Answers series offer the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary, and illustrative diagrams and flowcharts. This chapter presents sample exam questions along with examiner’s tips, answer plans, and suggested answers about EU law on sex discrimination and equality. The questions have been divided into a general question on the inclusion of sex discrimination provision in the first place; problem questions on aspects of equal pay and equal treatment; an essay question on a specific development in this area of law, which considers the overlapping area of pay and pensions and a problem on pregnancy-related matters. A new essay type question has been introduced on the expansion of areas protected by equality legislation at the end of the chapter.
5. Registered Land
Authors: Malcolm Rosalind
Published: September 2018

The Q&A series offer the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and illustrative diagrams and flowcharts. This chapter presents questions on registered land.
10. Easements and Profits
Authors: Malcolm Rosalind
Published: September 2018

The Q&A series offer the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and illustrative diagrams and flowcharts. This chapter looks at easements and profits.
3. The Three Certainties and Formalities
Authors: Malcolm Rosalind
Published: September 2018

The Concentrate Questions and Answers series offer the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans, suggested answers and author commentary. This book offers advice on what to expect in exams and how best to prepare. This chapter covers questions on the three certainties and formalities.
5. Trusts, Powers, and Discretionary Trusts
Authors: Malcolm Rosalind
Published: September 2018

The Concentrate Questions and Answers series offer the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans, suggested answers and author commentary. This book offers advice on what to expect in exams and how best to prepare. This chapter covers questions on trusts, powers, and discretionary trusts.
9. Share Capital
Authors: Moore Imogen
Published: September 2018

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions and coursework. Each book includes typical questions, suggested answers with commentary, illustrative diagrams, guidance on how to develop your answer, suggestions for further reading, and advice on exams and coursework. This chapter examines the law on share capital. The doctrine of capital maintenance ensures that the company has raised the capital it claims to have raised; and that the capital is not subsequently returned, directly or indirectly, to the shareholders. There is a great deal of (mainly statutory) law surrounding this doctrine This chapter considers the capital maintenance doctrine itself and many related topics, including: the issue of shares for non-cash consideration; issue of shares at a discount; reduction of capital; purchase of a company’s own shares; redeemable shares; payment of dividends; and financial assistance by a company for the purchase of its own shares.
10. Loan Capital
Authors: Moore Imogen
Published: September 2018

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions and coursework. Each book includes typical questions, suggested answers with commentary, illustrative diagrams, guidance on how to develop your answer, suggestions for further reading, and advice on exams and coursework. This chapter examines loan capital—borrowing by companies. It focuses on: the legal distinction between fixed and floating charges created by companies over their assets as security for loans; the registration of charges; applications for extension of the period for registration; the priority of charges on insolvency; and the avoidance of charges under the Insolvency Act 1986.
3. The European Convention on Human Rights
Authors: Foster Steve
Published: September 2018

The Concentrate Questions and Answers series offer the best preparation for tackling exam questions. Each book includes typical questions, diagram answer plans, caution advice, suggested answers, illustrative diagrams and flowcharts, and advice on gaining extra marks. Concentrate Q&A Human Rights & Civil Liberties offers expert advice on what to expect from your human rights and civil liberties exam, how best to prepare, and guidance on what examiners are really looking for. Written by experienced examiners, it provides: clear commentary with each question and answer; bullet point and diagram answer plans; tips to make your answer really stand out from the crowd; and further reading suggestions at the end of every chapter. The book should help you to: identify typical law exam questions; structure a first-class answer; avoid common mistakes; show the examiner what you know; make your answer stand out from the crowd.

This chapter examines the European Convention on Human Rights and the role of the European Court of Human Rights.
7. Supporting evidence: Lies, identification evidence, and suspect witnesses
Authors: Spencer Maureen , Spencer John
Published: September 2018

The Concentrate Questions and Answers series offers the best preparation for tackling exam questions. Each book includes typical questions, bullet-pointed answer plans and suggested answers, author commentary and illustrative diagrams and flow charts. This chapter discusses supporting evidence, which is variously referred to in textbooks as hazardous evidence, supporting evidence or safeguards against unreliability and error. Supporting evidence encompasses types of evidence that might intrinsically be of questionable reliability and, therefore, require supportive evidence. Key areas are disputed identification and lies told by the defendant. It is important to be familiar with the two distinct ways that the reliability of identification evidence is enhanced: first, the judge should issue the Turnbull guidelines; and, secondly, Code D of the Codes of Practice of the Police and Criminal Evidence Act 1984 should be followed in relation to identification procedures.
7. The Human Rights Act 1998
Authors: Clements Richard
Published: September 2018

The Q&A series offers the best preparation for tackling exam questions. Each chapter includes typical questions; diagram problem and essay answer plans, suggested answers, notes of caution, tips on obtaining extra marks, the key debates on each topic and suggestions on further reading. This chapter describes issues relating to the Human Rights Act 1998. The questions presented here deal with issues such as the response to terrorism; the effect of the Human Rights Act 1998 on English law; whether the Human Rights Act 1998 should be replaced with a UK bill of rights; the Human Rights Act not changing parliamentary supremacy, but the courts being able to issue a declaration of incompatibility; and the effect of the Human Rights Act on individual rights.
9. Freedom of expression
Authors: Clements Richard
Published: September 2018

The Q&A series offers the best preparation for tackling exam questions. Each chapter includes typical questions; diagram problem and essay answer plans, suggested answers, notes of caution, tips on obtaining extra marks, the key debates on each topic and suggestions on further reading. This chapter moves on from the previous one to examine the freedom of expression. Under common law, freedom of speech is guaranteed unless the speaker breaks the law, but this is now reinforced by the right of free expression under the European Convention on Human Rights. The questions here deal with issues such as obscenity law and contempt of court; the Official Secrets Act; freedom of information; breach of confidence and whether there is a right of privacy in English law.
Kidney diseases associated with Waldenström macroglobulinemia
Authors: Uppal Nupur N , Monga Divya , Vernace Melchiore A , Mehtabdin Khurram , Shah Hitesh H , Bijol Vanesa , Jhaveri Kenar D
Published: September 2018

Waldenström macroglobulinemia (WM) is a rare B-cell lymphoma characterized by lymphoplasmacytic cell infiltration in the bone marrow and other organs and the presence of a monoclonal immunoglobulin M protein in the serum. Although uncommon, several kidney diseases have been associated with WM. In addition to kidney diseases related to lymphoplasmacytic lymphoma infiltration, a variety of glomerular and tubular lesions have been described in patients with WM. Immunoglobulin light chain (AL) amyloidosis and cryoglobulinemic glomerulonephritis are the two predominant glomerular pathologies seen in WM. In this article we review the kidney diseases associated with WM. We also briefly review some nephrotoxicities of novel chemotherapeutic and targeted therapies used for the treatment of WM.
Refugee Migration and Electoral Outcomes
Authors: Dustmann Christian , Vasiljeva Kristine , Piil Damm Anna
Published: September 2018

To estimate the causal effect of refugee migration on voting outcomes in parliamentary and municipal elections in Denmark, our study is the first that addresses the key problem of immigrant sorting by exploiting a policy that assigned refugee immigrants to municipalities on a quasi-random basis. We find that in all but the most urban municipalities, allocation of larger refugee shares between electoral cycles leads to an increase in the vote share for right-leaning parties with an anti-immigration agenda, and we show large differences in voters’ responses to refugee allocation according to pre-policy municipal characteristics. However, in the largest and urban municipalities, refugee allocation has—if anything—the opposite effect on vote shares for anti-immigration parties. This coincides with a sharp divide in attitudes to refugees between urban and rural populations, which may be partly explained by distinctive interactions between natives and those with different background in cities and rural areas. Refugee allocation also has a large impact on the anti-immigration parties’ choice of where to stand for municipal election, and we provide some evidence that it influences voter turnout.
Effectiveness of Transcutaneous Electrical Nerve Stimulation Energy in Older Adults: A Pilot Clinical Trial
Authors: García-Pérez Sara , García-Ríos Ma Carmen , Pérez-Mármol José Manuel , Tapia-Haro Rosa María , Albornoz-Cabello Manuel , Valenza Marie Carmen , Aguilar-Ferrándiz María Encarnación
Published: September 2018

OBJECTIVE:

To evaluate the effectiveness of a transcutaneous electric nerve stimulation (TENS) device typically used for pain suppression (analgesia) during pressure injury (PI) healing, peripheral vascularization, and secondary pain in older adults with chronic PIs and cognitive impairment.

DESIGN AND SETTING:

This pilot clinical trial followed patients from 6 nursing homes.

PATIENTS AND INTERVENTION:

Twenty-two patients with PIs in the distal third of their lower limbs (7 men, 15 women) were included in this study. The control group completed standard wound care (SWC), whereas the experimental group received SWC and TENS. A total of 20 sessions were conducted for each group over 2 months, 3 times a week.

MAIN OUTCOME MEASURE:

PI area, PI healing rate, blood flow, skin temperature, oxygen saturation, and level of pain at baseline and posttreatment.

MAIN RESULTS:

Significant improvements were achieved in PI area (mean difference, 0.92; 95% confidence interval [CI], 0.15–1.67; P =.024), healing rate (3; 95% CI, 1–4.99; P =.009), skin temperature (1.82; 95% CI, 0.35–3.28; P =.021), and pain (1.44; 95% CI, 0.49–2.39; P =.008) in the experimental group, whereas none of the variables revealed a significant change in the control group.

CONCLUSIONS:

The effect of local and spinal TENS combined with the SWC for PI produced a significant improvement in size, healing, skin temperature, and pain levels.
Improvement in Work Ability, Psychological Distress and Pain Sites in Relation to Low Back Pain Prognosis
Authors: Nordstoga Anne L. , Vasseljen Ottar , Meisingset Ingebrigt , Nilsen Tom I. L. , Unsgaard-Tøndel Monica
Published: September 2018

Study Design.

Prospective observational study pooled from two clinical cohorts.

Objective.

To investigate the longitudinal relation between multisite pain, psychological distress, and work ability with disability, pain, and quality of life.

Summary of Background Data.

Knowledge of prognostic factors is essential for better management of patients with low back pain (LBP). All domains of the biopsychosocial model have shown prognostic value; however, clinical studies rarely incorporate all domains when studying treatment outcome for patients with LBP.

Methods.

A total of 165 patients with nonspecific LBP seeking primary care physiotherapy were included. Mixed-effects models were used to estimate longitudinal relations between the exposure variables and concurrent measures of outcomes at baseline and 3 months. Logistic regression was used to estimate odds ratios for minimal important difference in outcome.

Results.

Higher work ability was associated with less disability −2.6 (95% confidence interval [CI]: −3.3, −2.0), less pain: −0.4 (95% CI: −0.5, −0.3), and higher quality of life 0.03 (95% CI: 0.02, 0.04). Higher psychological distress and number of pain sites were associated with higher disability: 10.9 (95% CI: 7.7, 14.1) and 2.3 (95% CI: 1.4, 3.2) higher pain: 1.9 (95% CI: 1.3, 2.5) and 0.4 (95% CI: 0.2, 0.5), and lower quality of life: −0.1 (95% CI: −0.2, −0.1) and −0.02 (95% CI: −0.03, −0.01), respectively. Improvement in work ability showed consistent associations with successful outcome for disability (odds ratio [OR]: 4.8, 95% CI: 1.3, 18.1), pain (OR: 3.6, 95% CI: 1.1, 12.1), and quality of life (OR: 4.5, 95% CI: 1.4, 15.1) at 3 months. Reduced psychological distress was associated with improvement in pain only (OR 4.0, 95% CI: 1.3, 12.3).

Conclusion.

More pain sites, higher psychological distress, or lower work ability showed higher disability, more pain, and lower quality of life in patients with LBP. Only improvement in work ability was consistently related to successful outcomes.

Level of Evidence: 2
Changes in the Use of Lumbar Arthrodesis Procedures Within Accountable Care Organizations
Authors: Schoenfeld Andrew J. , Sturgeon Daniel J. , Harris Mitchel B. , Blucher Justin A. , Kang James D. , Haider Adil H. , Bono Christopher M.
Published: September 2018

Study Design.

A retrospective review of Medicare claims data (2009–2014).

Objective.

The aim of this study was to evaluate changes in the use of lumbar fusion procedures following the formation of Accountable Care Organizations (ACOs).

Summary of Background Data.

Within surgical care afforded by ACOs, savings are thought to be realized by improved care coordination as well as reductions in the use of preference-sensitive procedures such as lumbar fusion.

Methods.

We queried fee-for-service claims for patients enrolled in Medicare Part A and B, identifying patients who received lumbar spine fusion, discectomy, or decompression procedures. We performed a difference-in-differences analysis comparing the use of lumbar fusion in ACOs and non-ACOs in the period before (2009–2011) and after (2012–2014) ACO formation. Propensity score adjustment was used to address differences in case-mix. Multivariable logistic regression was used to compare the likelihood of receiving a lumbar fusion in ACOs and non-ACOs in the period before and after ACO formation.

Results.

Within organizations that would form ACOs, the raw rate of lumbar fusion increased from 50% (n = 2183) in 2009 to 2011 to 54% (n = 2283) in 2012 to 2014. Among non-ACOs, the use of fusion increased from 52% (n = 110,160) to 59% (n = 109,917). Adjusted difference in differences in the use of lumbar fusion between ACOs and non-ACOs was -2.6 percentage points (P = 0.13). When limited to patients with spinal stenosis, ACOs significantly reduced the use of fusion (-5.8 percentage points; P = 0.03).

Conclusion.

Our results indicate that ACOs may effectively curtail the use of lumbar fusion procedures, particularly among patients with spinal stenosis. As these interventions are often associated with higher complications and need for reoperation, such practices might accrue additional health care savings for Medicare beyond those realized during the index surgical period.

Level of Evidence: 3
Risk of Surgical Site Infection and Mortality Following Lumbar Fusion Surgery in Patients With Chronic Steroid Usage and Chronic Methicillin-Resistant Staphylococcus aureus Infection
Authors: Singla Anuj , Qureshi Rabia , Chen Dennis Q. , Nourbakhsh Ali , Hassanzadeh Hamid , Shimer Adam L. , Shen Francis H.
Published: September 2018

Study Design.

A retrospective database analysis among Medicare beneficiaries

Objective.

The aim of this study was to determine the effect of chronic steroid use and chronic methicillin-resistant Staphylococcus aureus (MRSA) infection on rates of surgical site infection (SSI) and mortality in patients 65 years of age and older who were treated with lumbar spine fusion.

Summary of Background Data.

Systemic immunosuppression and infection focus elsewhere in the body are considered risk factors for SSI. Chronic steroid use and previous MRSA infection have been associated with an increased risk of SSI in some surgical procedures, but their impact on the risk of infection and mortality after lumbar fusion surgery has not been studied in detail.

Methods.

The PearlDiver insurance-based database (2005–2012) was queried to identify 360,005 patients over 65 years of age who had undergone lumbar spine fusion. Of these patients, those who had been taking oral glucocorticoids chronically and those with a history of chronic MRSA infection were identified. The rates of SSI and mortality in these two cohorts were compared with an age- and risk-factor matched control cohort and odds ratio (OR) was calculated.

Results.

Chronic oral steroid use was associated with a significantly increased risk of 1-year mortality [OR = 2.06, 95% confidence interval (95% CI) 1.13–3.78, P = 0.018] and significantly increased risk of SSI at 90 days (OR = 1.74, 95% CI 1.33–1.92, P < 0.001) and 1 year (OR = 1.88, 95% CI 1.41–2.01, P < 0.001). Chronic MRSA infection was associated with a significantly increased risk of SSI at 90 days (OR = 6.99, 95% CI 5.61–9.91, P < 0.001) and 1 year (OR = 24.0, 95%CI 22.20–28.46, P < 0.001) but did not significantly impact mortality.

Conclusion.

Patients over 65 years of age who are on chronic oral steroids or have a history of chronic MRSA infection are at a significantly increased risk of SSI following lumbar spine fusion.

Level of Evidence: 3
Epidemiological State, Predictors of Early Mortality, and Predictive Models for Traumatic Spinal Cord Injury
Authors: Shibahashi Keita , Nishida Masahiro , Okura Yoshihiro , Hamabe Yuichi
Published: September 2018

Study Design.

Multi-center, retrospective cohort study.

Objective.

To determine the epidemiology, identify predictors of early mortality, and develop predictive models for traumatic spinal cord injury (SCI).

Summary of Background Data.

Despite improved initial care and management strategies, traumatic SCI remains a devastating event. Knowledge of the epidemiological state and predictive factors for mortality is important for developing strategies and counseling; however, they have not been adequately investigated, and predictive modeling regarding outcomes remains an underused modality for patients with traumatic SCI.

Methods.

Using a nationwide trauma registry—the Japan Trauma Data Bank—we identified adult (≥18 yrs) patients with SCI between 2004 and 2015. The endpoint was in-hospital mortality. Characteristics of each patient were described. Multivariate logistic regression analyses were performed to identify factors significantly associated with in-hospital mortality and develop a predictive model.

Results.

In total, 236,698 patients were registered in the database. Of the 215,835 adult patients, 8069 (3.7%) had SCI. The majority had SCI at the cervical level with falls at ground level being the primary etiology. Over the study period, median age, the proportion of cervical SCI, and the etiology of falls at ground level increased. The mortality rate was 5.6%. The following eight factors, age, sex, Glasgow Coma Scale on arrival (GCS), hypotension on arrival, bradycardia on arrival, severe head injury, Injury Severity Score (ISS), and neurological severity of SCI, were independently associated with mortality. A predictive model consisting of these variables predicted mortality with area under the receiver operating characteristic curve of 0.88 (95% confidence interval [CI], 0.86–0.90).

Conclusion.

Over the 12-year period, patient characteristics, etiology, and post-SCI outcomes significantly changed. We identified eight prognostic factors of early mortality. A predictive model including these factors showed excellent performance and may improve treatment strategies, healthcare resource allocation, and counseling.

Level of Evidence: 3
Comparison of Postoperative Outcomes According to Compensatory Changes of the Thoracic Spine Among Patients With a T1 Slope More Than 40°
Authors: Oe Shin , Togawa Daisuke , Yamato Yu , Yoshida Go , Hasegawa Tomohiko , Kobayashi Sho , Yasuda Tatsuya , Banno Tomohiro , Arima Hideyuki , Mihara Yuki , Ushirozako Hiroki , Matsuyama Yukihiro
Published: September 2018

Study Design.

Retrospective study of postoperative outcomes of adult spinal deformity (ASD) surgery.

Objective.

To clarify the differences in postoperative outcomes depending on the presence or absence of thoracic compensatory changes among patients with a T1 slope (TS) more than 40°.

Summary of Background Data.

Loss correction after ASD surgery is more likely to occur when preoperative TS is more than 40°. When preoperative TS is more than 40°, some cases involve compensatory changes in the thoracic spine and decreased thoracic kyphosis (TK); others involve increased TK without compensatory changes.

Methods.

Seventy-nine patients with TS more than 40° who underwent ASD surgery were enrolled and separated into compensated and noncompensated groups (group C: TK <40°; group NC: TK ≥40°). Radiographic parameters obtained by whole-spine standing x-ray, the Oswestry Disability Index (ODI), and Scoliosis Research Society-22 (SRS-22) questionnaire were assessed.

Results.

There were 41 patients in group C and 38 patients in group NC. Preoperative significant differences in TS did not disappear after surgery (preoperative TS: group C and group NC = 46° and 55°, P < 0.001; just after surgery: group C and group NC = 27° and 40°, P < 0.001; 2 years later: group C and group NC = 34° and 47°, P < 0.001). There were no significant differences in ODI and all domains of the SRS-22 before surgery. However, 2 years after the surgery, ODI (38%), pain (3.5), self-image (3.0), and total (3.2) values of the SRS-22 for group NC were significantly worse than those (28%, 4.0, 3.4, and 3.5, respectively) for group C (P < 0.05).

Conclusion.

Changes in the thoracic spine (TS and TK >40°) result in poor postoperative outcomes. Extending the upper instrumented vertebra (UIV) to the upper thoracic spine must be considered. Even when TS is more than 40°, TK less than 40°, and upper instrumented vertebra set to the lower thoracic level result in good postoperative outcomes.

Level of Evidence: 3
Safety and Efficacy of Revision Minimally Invasive Lumbar Decompression in the Ambulatory Setting
Authors: Hirsch Brandon P. , Khechen Benjamin , Patel Dil V. , Cardinal Kaitlyn L. , Guntin Jordan A. , Singh Kern
Published: September 2018

Study Design.

A retrospective analysis.

Objective.

The aim of this study was to investigate differences in perioperative outcomes between patients undergoing revision minimally invasive lumbar spine decompression (MIS LD) in the ambulatory and hospital-based surgical settings.

Summary of Background Data.

Revision LD has been associated with an increased risk of complications compared with primary LD. Furthermore, ambulatory primary LD has been demonstrated to be a safe and viable option in appropriately selected patients. However, there is a paucity of information comparing hospital-based versus ambulatory outcomes in revision LD.

Methods.

A prospectively maintained surgical registry of patients undergoing revision MIS lumbar laminectomy and/or discectomy for degenerative pathology from 2013 to 2017 was retrospectively reviewed. Propensity score matching was performed to adjust for measured confounding variables, including patient age, comorbidity burden as measured by Charlson Comorbidity Index, and preoperative diagnosis. Differences in operative variables, complication rates, pain scores, narcotics consumption, and reoperation rates were assessed using Pearson Chi-squared analysis (categorical) and Student t test (continuous).

Results.

Seventy patients were included, of whom 35 underwent revision MIS LD at a hospital-based center (HBC), and 35 underwent surgery at an ambulatory surgical center (ASC). HBC and ASC patients demonstrated similar postoperative visual analog scale pain scores and hourly narcotics consumption during surgical stay (P < 0.001). ASC patients exhibited a significantly shorter length of stay than hospital-based patients (2.7 vs. 11.6 hours, P < 0.001).

Conclusion.

Patients undergoing revision MIS LD in an ASC demonstrated similar perioperative outcomes as compared to patients undergoing revision MIS LD in a HBC. These results suggest that revision MIS LD can be performed safe and effectively in the ambulatory setting in an appropriately selected surgical population. Further study of patient outcomes following spine surgery performed outside of the traditional hospital setting is crucial, as the delivery of care in the ambulatory setting continues to grow in popularity.

Level of Evidence: 3
Safety of Outpatient Single-level Cervical Total Disc Replacement
Authors: Bovonratwet Patawut , Fu Michael C. , Tyagi Vineet , Ondeck Nathaniel T. , Albert Todd J. , Grauer Jonathan N.
Published: September 2018

Study Design.

A retrospective cohort comparison study.

Objective.

The aim of this study was to investigate the perioperative adverse event profile of cervical total disc replacement (CTDR) performed as an outpatient relative to inpatient procedure.

Summary of Background Data.

Recent reimbursement changes and a push for safe reductions in hospital stay have resulted in increased interest in performing CTDRs in the outpatient setting. However, there has been a paucity of studies investigating the safety of outpatient CTDR procedures, despite increasing frequency.

Methods.

Patients who underwent single-level CTDR were identified in the 2005 to 2016 National Surgical Quality Improvement Program database. Outpatient versus inpatient procedure status was defined by length of stay, with outpatient being less than 1 day. Patient baseline characteristics and comorbidities were compared between the two groups. Propensity score matched comparisons were then performed for 30-day perioperative complications and readmissions between the two cohorts. In addition, perioperative outcomes of outpatient single-level CTDR versus matched outpatient single-level anterior cervical discectomy and fusion (ACDF) cases were compared.

Results.

In total, 373 outpatient and 1612 inpatient single-level CTDR procedures were identified. After propensity score matching was performed to control for potential confounders, statistical analysis revealed no significant difference in perioperative complications between outpatient versus matched inpatient CTDR. Notably, the rate of readmissions was not different between the two groups. In addition, there was no difference in rates of perioperative adverse events between outpatient single-level CTDR versus matched outpatient single-level ACDF.

Conclusion.

The perioperative outcomes evaluated in the current study support the conclusion that, for appropriately selected patients, single-level CTDR can be safely performed in the outpatient setting without increased rates of 30-day perioperative complications or readmissions compared with inpatient CTDR or outpatient single-level ACDF.

Level of Evidence: 3
Incidence, Risk Factors, and Clinical Implications of Postoperative Hematoma Requiring Reoperation Following Anterior Cervical Discectomy and Fusion
Authors: Bovonratwet Patawut , Fu Michael C. , Tyagi Vineet , Bohl Daniel D. , Ondeck Nathaniel T. , Albert Todd J. , Grauer Jonathan N.
Published: September 2018

Study Design.

Retrospective study of prospectively collected data.

Objective.

To determine the incidence, timing, risk factors, and clinical implications of postoperative hematoma requiring reoperation after anterior cervical discectomy and fusion (ACDF).

Summary of Background Data.

Postoperative hematomas requiring reoperation are rare but potentially catastrophic complications after ACDF. However, there has been a lack of large cohort studies investigating these complications in the ACDF population despite increasing outpatient procedure volume.

Methods.

Patients who underwent ACDF in the 2012 to 2016 National Surgical Quality Improvement Program database were identified. The primary outcome was an occurrence of hematoma requiring reoperation within 30 days postoperatively. Risk factors for this outcome were identified using multivariate regression. Postoperative length of stay, subsequent complications, and mortality were compared between patients who did and did not develop a hematoma requiring reoperation.

Results.

A total of 37,261 ACDF patients were identified, of which 148 (0.40%) developed a hematoma requiring reoperation (95% confidence interval [CI], 0.33%–0.46%). Of the cases that developed this complication, 37% occurred after discharge. Risk factors for the development of hematoma requiring reoperation were multilevel procedures (most notably ≥3 levels, relative risk [RR] = 3.14, 95% CI = 1.86–5.32, P < 0.001), preoperative international normalized ratio >1.2 (RR = 2.85, 95% CI = 1.42–5.71, P = 0.006), lower BMI (notably body mass index ≤24, RR = 2.11, 95% CI = 1.21–3.67, P = 0.008), American Society of Anesthesiologists classification ≥3 (RR = 2.07, 95% CI = 1.47–2.91, P < 0.001), preoperative anemia (RR = 1.71, 95% CI = 1.12–2.63, P = 0.027), and male sex (RR = 1.67, 95% CI = 1.18–2.37, P = 0.004). In addition, patients who developed a hematoma requiring reoperation before discharge had a longer length of stay. Further, those who developed a hematoma requiring reoperation were at higher risk for subsequent ventilator requirement, deep wound infection, pneumonia, and reintubation.

Conclusion.

Postoperative hematoma requiring reoperation occurred in approximately 1 in 250 patients after ACDF. High-risk patients should be closely monitored through the perioperative period.

Level of Evidence: 3
Changes in health behaviours and body mass index after a breast cancer diagnosis: results from a prospective cohort study
Authors: Barbosa Ana , Costa Ana Rute , Fontes Filipa , Dias Teresa , Pereira Susana , Lunet Nuno
Published: September 2018

The aim of the study was to describe changes in health behaviours and BMI after breast cancer diagnosis, depicting the potential influence of sociodemographic, clinical and psychological characteristics. A total of 428 breast cancer patients were prospectively followed for 3 years, since diagnosis. At the end of follow-up, women were classified regarding their adherence to recommendations for cancer prevention, prediagnosis and after 3 years, including not smoking, alcohol consumption up to one drink per day, intake of at least five portions per day of fruits and/or vegetables, physical activity and body mass index (BMI) less than 25.0 kg/m2. To quantify associations between patients’ characteristics and changes in adherence to each recommendation, age, education and cancer stage-adjusted odds ratio (OR) with 95% confidence intervals (CIs) were calculated. Among women adhering to each recommendation before diagnosis, 54.1% reduced their physical activity, 32.4% became overweight or obese and 6.1% reduced fruits and/or vegetables intake, but there were virtually no changes in alcohol consumption or smoking. Older and more educated participants were more likely to reduce their physical activity (OR=4.71, 95% CI: 1.17–18.99; OR=11.53, 95% CI: 2.20–60.53, respectively). Among participants not following each recommendation before diagnosis, 29.1% stopped smoking, 24.6% reduced alcohol consumption, 9.9% became physically active, 7.8% increased fruits and/or vegetables intake and 3.3% reduced their BMI to less than 25.0 kg/m2. Older women were less likely to become physically active (OR=0.32, 95% CI: 0.14–0.75). Breast cancer patients showed some positive changes in their health behaviours after diagnosis. However, there is a large margin for improvement, which highlights the importance of health promotion interventions in this context.