bluuebunny/crossref_metadata_2025 huggingface dataset:
Role of urban design and planning in disaster risk reduction
Authors: Chmutina Ksenia , Ganor Tamar , Bosher Lee
Published: March 2014

Recent disasters in cities worldwide have highlighted the fragility of built environments to a range of hazards and increased concerns about the resilience of cities, with contemporary discussions considering how physical/protective interventions can be integrated into the built environment. It is important for the numerous stakeholders involved with the construction industry to take responsibility for integrating disaster risk reduction (DRR) activities into the planning, (re)design, construction and operation of the built environment. It is fundamentally important to understand which stakeholders should be involved and when their inputs are needed. Utilising two case studies in Jerusalem and Nottingham the role of key stakeholders in the integration of DRR activities into the urban design and planning process is evaluated. It is argued that there is a general lack of consensus regarding the roles of stakeholders and their levels of participation. This paper identifies the commonalities and differences between key stakeholders who should be responsible for integrating DRR activities into urban design and planning and emphasises the gaps in stakeholders' involvement. It is argued that there is a need to engage construction stakeholders with a wider range of stakeholders who are typically not extensively involved in DRR, and ensure interaction among them.
Policy challenges for transit-oriented development
Authors: Hakkaart Aaron , Morrissey John Edward
Published: March 2014

Australasian cities are highly car dependent as a result of historical development patterns. Given peak oil and climate change challenges, these patterns are clearly not sustainable. Transit-oriented development presents an alternative urban development paradigm. Under transit-oriented development principles, urban development integrates with mass transit provision, based on a commitment to development centred on transit hubs. Transit-oriented development represents a radical challenge to business as usual for planners, developers and private enterprise. This study considers the case of Wellington, New Zealand, and examines the progress made to implement transit-oriented development within the existing planning regime. Barriers and opportunities for the integration of transit-oriented development are discussed, as are the implications of these. Results indicate that significant changes need to take place within the current planning framework if transit-oriented development is to become viable. More broadly, challenges and opportunities for the application of transit-oriented development principles in car-dependent cities are identified, together with implications for decision-makers.
In the Shadow of Tolerance: The Discursive Context of Dutch-Born Muslim Youth
Authors: Zaal Mayida
Published: March 2014

Despite a public discourse on tolerance, anxiety about immigrants, Islam and the preservation of Dutch values has amplified fear of Muslim youth in the Netherlands. In this context, Dutch-born Muslim youth endure social and systemic discrimination that affects all aspects of their futures, including available educational opportunities and eventually their prospects for employment. ased on a one-year qualitative study conducted in Amsterdam, this article explores the lived experience of Dutch-born Muslim youth caught at the intersection of national policies and local realities. Grounded in critical literature originating in the Netherlands and in Europe, this inquiry triangulates participant observations, focus groups with youth ( n = 25) and interviews with youth workers ( n = 25) to disclose the hostile discursive contexts faced by Muslim youth. Findings indicate that anti-Muslim and anti-immigrant discourses permeate the everyday experiences of Muslim youth, including the practices and structures of youth programs they attend. The study raises questions about multicultural policies that appear progressive and attempt to build social cohesion but may in fact further alienate and oppress Muslim youth. It also reveals how Muslim youth navigate oppression by agentically constructing their identities while resisting the dehumanizing categories in which they are placed.
Muslim Education and its (In)commensurability with Multiculturalism: Some Thoughts on the Imaginative Madrassah
Authors: Waghid Yusef , Davids Nuraan
Published: March 2014

Muslim education is not incommensurate with multiculturalism and, hence, does not pose a threat to multiculturalism at all. If Muslim education were to be perceived as a risk to multiculturalism then either such a form of education is not conceived appropriately or the claims of multiculturalism are false. Instead, the authors argue that Muslim education can engender multiculturalism — that is, Muslim education is attuned to multiculturalism. Moreover, they contend that Muslim education has the potential to give rise to new imaginings, which augurs well for the madrassah — that is, the educational institution often pejoratively accused of instigating violence. Instead, they argue that the imaginative madrassah can be considered as a seedbed for vigilance and recognition of the other — those virtues that can harness multicultural practices.
Multiculturalism is D(r)ead in Europe
Authors: Bajrektarevic Anis
Published: March 2014

There is a claim currently circulating the European Union (EU), both cynical and misleading: ‘multiculturalism is dead in Europe’. No wonder, as the conglomerate of nation-states/EU has silently handed over one of its most important debates — that of European identity — to the left and right wing parties, recently followed by several selective and contra-productive foreign policy actions. Europe's domestic cohesion, its fundamental realignment, as well as the overall public standing and credibility within its strategic neighborhood, lies in the reinvigoration of its everything but institutions transformative powers — stipulated in the Barcelona process of the European Neighborhood Policy as well as in the Euro-Med partnership (OSCE).
Our Little Land and the Urgency of Showing, Not Telling, Our Subjectivities
Authors: Reinertsen Anne Beate , Otterstad Ann Merete , Ben-Horin Oded
Published: March 2014

This is a collaborative writing story in which songs and poems invite us into complexities of living the ideals and calling for new ways of making the world visible. I need to show you who I am. You need to show me who you are. They are never completed, always open to self and social reflection, and hopefully capable of pushing boundaries of both our personal and collective imaginations and struggles against injustice and xenophobia, wherever they might be, further. We have a focus on becomings rather than belongings. Poems, music, pictures and lyrics, layout and stream-of-thought writing blend with materialist and social science discourses: we need ‘noise’ and ‘pulse’ in our systems to make them function. Noise is creative. Noise is difficult, but not necessarily a threat.
The Religious Aspects of Diasporic Experience of Muslims in Europe within the Crisis of Multiculturalism
Authors: Habti Driss
Published: March 2014

The literature on migration has largely covered concepts of diaspora, such as transnationalism, immigration and religious-ethnic minorities. These concepts that concern related factors of social transformation, mainly with reference to Islam in Europe, have been investigated with respect to religion. Major research questions include whether, and how, Muslim communities in Europe keep self-identity and how they adapt to the environment without abandoning group identity. This article examines Muslim diaspora with its different facets in Europe, and with religion as a dynamic factor in diasporic social transformation. The study presents a delineation of this diaspora and its conflation with the issue of immigration, transnationalism and identity, and the dynamics of religious transformation within the Muslim diasporic space. Reference will be made to the theoretical framework developed by Steven Vertovec on diaspora, transnationalism and migration in its relation to religion. The article follows two major theoretical premises: (i) whether national identity and citizenship policy, as defined and regulated by political bodies, are politically charged; and (ii) the question of multiculturalism and integration in Europe in terms of the encounter between Islamic values and putatively ‘secular’ European values, in a time when multiculturalism has been shifted to an ‘assimilative’ mode of integration.
The Hijab and the Integration of the Muslim Other in Spanish Schools
Authors: Depalma Renee , Lopez Laura Cruz
Published: March 2014

The social integration of migrant populations has been defined as an intercultural, mutually enriching process, and can be distinguished from processes of assimilation that involve a more unilateral adaptation on the part of immigrants to the norms of the host country. In Spain, this distinction has become blurred in both political and educational policy discourses. In this article the authors analyse an incident that occurred in 2011 in which an 11-year-old girl was expelled from her school for wearing a hijab, one of two such cases in Spain and the first of its kind in the autonomous community of Galicia. The initial argument as expressed in the school policy reveals an essentialist and assimilationist understanding of culture in terms of the norms of the host society: students were expected to ‘keep their heads exposed’ in class as a ‘sign of respect’. Based on press reports, policy documents and legal proceedings, the authors interrogate the discourses deployed by the school and the local educational administration officials, politicians, Muslim community representatives and the family directly involved in the case, focusing on the ways in which they reveal an overall assimilationist vision of Spanish—Muslim intercultural community relations at the level of school policy.
Citizenship Education and National Identity: Teaching Ambivalence
Authors: Ljunggren Carsten
Published: March 2014

The article is concerned with issues of national identity in a multicultural society (Sweden) and the role of citizenship education in creating a national identity. After having witnessed the terrorist attack and the traumas from Oslo and Utøya (22 July 2011), and the suicide bombing in Stockholm on 11 December 2010, certain words, such as national identity and patriotism, make the project of writing on national identity from a Scandinavian perspective not just urgent but somewhat problematic. What the author terms national identity and democratic patriotism in the article is intended to combat all forms of chauvinistic ethno-nationality, on the one hand, and, on the other, fundamental ethno-religious identity. He argues for a particular way of understanding national identity that transcends ethnicity but also acknowledges it, by elaborating on the conception of ‘democratic patriotism’. In this respect, his discussion of this issue is framed by the discussion of social integration and its importance to citizenship education, where his intention is to discriminate between the kind of national identity that refers either to aspects of political domination or a cultural hegemony, or both, and democratic and critical understanding of national identity in relation to pluralism and contingency (i.e. concerning respect for difference and otherness). The purpose of this article is to provide theoretical and empirical arguments for a didactical professional attitude and the practice of reciprocal communication in this sense where meanings of national identity are discussed, tested and challenged in class. In light of the ongoing debate, the article is a revisiting of concepts and a debate over concepts of national identity and belonging: how national identity can be identified, and what might be done to affirm a constructive, democratic national identity beyond both nationalism and multiculturalism.
Teacher Attitudes toward Muslim Student Integration into Civil Society: A Report from Six European Countries
Authors: Sharpes Donald K. , Schou Lotte R.
Published: March 2014

The convergence of Islam and national and cultural identity in Europe, exacerbated by external events like a murder, assassination, riot, embassy bombing or even a satirical cartoon, has the potential for disrupting civic order and eroding movements towards cultural assimilation and national integration. Clearly, fundamentalism in any religion, Jewish, Christian, Sikh or Muslim, can turn a few radicals into fanatics who seek the death of those whom they believe are infidels. Revealing the sources of cultural dissonance between Islamic faith and national identity can have a profound influence on how societies prepare for Muslim immigrant problems throughout Europe and even America. This social science inquiry involving six European countries (Denmark, Norway, Belarus, Austria, Finland and Belgium) provides a modicum of evidence for the depth and level of educator attitudes regarding the Muslim student population beliefs about integration into civil society and about violence.
Multiculturalism Swedish Style: Shifts and Sediments in Educational Policies and Textbooks
Authors: Gruber Sabine , Rabo Annika
Published: March 2014

In the almost two decades that have passed since the Swedish parliament declared that Sweden is a multicultural society, debates about immigrants, about multiculturalism and about different ways of being a citizen have raged. So far there has been no stepping away from the declaration. In the rhetorical arena multiculturalism is still a word with positive connotations, but in the arena of political praxis the situation is different. Inequalities in access to social services, not least education, have increased dramatically, and these inequalities are typically correlated to immigrant background and place of residence. This article focuses on policy documents concerned with multiculturalism in Swedish education and textbooks. First of all, the analysis shows that although multiculturalism is inscribed in steering documents, the concept is never clearly defined but instead remains vague and malleable. Second, while the experiences of pupils with an immigrant background are typically said to bring variety to the classrooms and thus are useful for pedagogical purposes, textbooks seldom acknowledge that Sweden today is, indeed, a multicultural society.
Muslim Students in Malta: Citizens at the Margins
Authors: Chircop Louise
Published: March 2014

Malta is a small island at the periphery of Europe, often referred to as a bridge connecting Africa with the European continent. Discourse about multiculturalism opens a Pandora's box, albeit the very recently elected Labour Party won the election on the call of Malta Tagħna Lkoll (Malta belongs to all of us). This was the first time that political parties courted the approximately 6000 Muslims who form part of the population. This is surprising because there is usually reluctance to be associated with Muslims, especially if they hail from Arab countries. Muslims in Malta are not easily accepted, although they are tolerated. Schools generally provide a one-size-fits-all type of education, where diversity is acknowledged on paper but in practice it is often up to the individual schools to deal with diversity as they deem fit. The National Curriculum Framework and syllabi are imbued with references to Catholicism and often equate Maltese identity with being Catholic. On the whole, the hostility towards Muslims existing outside is often reflected in schools, through what Bourdieu calls symbolic violence. Very often Muslims are ignored, stereotyped, disrobed of their identity and vilified through educational practices. For such reasons, many Muslim parents choose to send their children to the only school for Muslims in Malta.
Austerity/Immiseration Capitalism and Islamophobia — Or Twenty-First-Century Multicultural Socialism?
Authors: Cole Mike
Published: March 2014

This article is in three parts. In part one, the author begins by examining the onset of austerity/immiseration capitalism in the United Kingdom. Austerity/immiseration capitalism has witnessed the decline of state multiculturalism and increasing attempts to deflect attention away from the failures of capitalism by playing the ‘race card’. At the same time, state multiculturalism has been replaced by ‘muscular liberalism’. As an absolute contrast to developments in the United Kingdom, in part two of the article, he discusses anti-racist multicultural twenty-first-century socialism in the making in the Bolivarian Republic of Venezuela. In part three of the article, the author assesses what needs to be done. For a permanent solution to austerity/immiseration capitalism and Islamophobia, the author suggests, we need to learn from the Venezuelan example.
Between the Cat and the Principle: An Encounter between Foucault's and Bourdieu's Conceptualisations of Power
Authors: Bang Lars
Published: March 2014

This article explores the benefits of an encounter between Foucault's and Bourdieu's different conceptualisations of power. The two approaches to power are considered by contemporary research to be irreconcilable, but this article claims that, by engaging both understandings, it is possible to draw a more nuanced map, one which is especially suited to research in power and discourse in educational fields. The article draws on the controversy between Heisenberg's uncertainty principle and Schrödinger's wave image (later formulated as Schrödinger's cat paradox) regarding the nature of the atom as an analogy to show why both conceptualisations are needed in order to understand the nature and manifestation of power. Does power operate as a hierarchy within the field, shaping the practices and habitus of the agents through various forms of capital (Schrödinger's wave image)? And is power distributed across fields and is it only through an archaeological and genealogical analysis that it is possible to get a glimpse of power, which is as elusive as Heisenberg's matrix theory (Heisenberg's uncertainty principle)? Analysing educational fields through an approach drawn from Bourdieu, the article applies sociology-specific methods to measure, quantify and visualise power on a contemporary, manifested and present level. Using a Foucauldian approach, it analyses the history of the present in order to understand how the above dilemma came to be and how it is distributed across various discourses, institutions and practices. It is argued that, when analysing power, a destabilised marriage between Foucault and Bourdieu is needed.
Doing Race: How Secondary School Pupils in Mainly White Schools Construct ‘Race’
Authors: Bennett Julia , Lee-Treweek Geraldine
Published: March 2014

This article examines how ‘race’ impacts upon the lives of young people who attend secondary schools in a mainly white British area of the United Kingdom. Schools Stand up 2 Racism (SSu2R), a Big Lottery research project, brought together a community partner – the Cheshire, Halton and Warrington Race and Equality Centre – and a team from Manchester Metropolitan University to investigate racism in Cheshire secondary schools. In an area where the population is over 93% ‘white British’, the sense that ‘there's nothing to be racist about in this school’ (Year 8 pupil) was found to be common. The three-year SSu2R study used a multimethod approach to study how students ‘do race’ in these schools, where the silent advocacy of a ‘colour-blind’ approach is promulgated through the popular rhetoric of ‘everyone is unique’ and ‘we should treat everyone the same’. Race is tackled only tangentially through the curriculum, accompanied by silences that close down discussion. Perhaps unsurprisingly given this context, forms of everyday racism are endemic and yet mostly unnoticed by staff or students. The article uses Bourdieu's concepts of ‘doxa’ and ‘the game’ to examine the nature of this silence.
Replacing the Misplaced: Power, Autobiography and Learner Identity
Authors: Choi Tat-Heung
Published: March 2014

This article is concerned with examining how social class as a key aspect of learner identity is modified, reinforced or transformed through educational progressions, whereupon relationships change, power is redistributed and different forms of capital are prized. The dynamics between structural and cultural influences on working-class relationships to education are explored by way of autobiographical writing, and analysed through the lens of habitus and field. In operationalising habitus, the indeterminacy of the concept rejects a close, unproblematic connection between class and education, questions the assumed homogeneity of class dispositions, and renders a more fluid and dynamic working of class and learner identity. Arguing against the synchronic view of language characterised by regularity and internal consistency, this methodological orientation of habitus chimes with a textual approach that values inferential enrichment and indeterminacy. Using critical discourse in genre analysis offers space for potentially subversive interpretations, or for playing with evaluative meanings, of an autobiographical account rooted in the local and particular, but also sets great store in understanding constraining and transformative courses of action. This modest inquiry illuminates the relevance of autobiographical reflection to the development of agency and educational capital, with an emphasis on temporality, continuity and change.
Beyond NEET: Precariousness, Ideology and Social Justice – the 99%
Authors: Avis James
Published: March 2014

This article addresses NEET (not in employment, education or training) as an ideological and discursive formation, lodging the discussion within its socio-economic context – one of increasing insecurity and precariousness. It argues that frequently quasi-political and ideological constructions of NEET can readily fold over into and articulate with discourses of the underclass and the broken society, as well as, paradoxically, social recession. Consequently, such arguments divert attention from processes of ‘othering’ and the secular changes facing society, as well as the spectre of a return to a form of nineteenth-century liberalism. Although the argument is located within the English context, it has a relevance to other Western societies in which similar tendencies can be discerned.
Discourses of Inclusion and Exclusion: Drawing Wider Margins
Authors: Slee Roger
Published: March 2014

Drawing upon the work of Richard Sennett and Zygmunt Bauman, this article examines the ubiquity of exclusion as a prelude to interrogating paradoxes in the deployment of discourses and practices of inclusive education, arguing that the ethic of competitive individualism that drives the formation of education policies and practices subverts aspirations for inclusive education. Moreover, it is argued that inclusive education provides a means for managing populations that threaten institutional equilibrium and attainment benchmarks. A series of recent reports, critical of education programmes and experiences for students with disabilities, is offered as evidence of the need for rethinking approaches to education reform in general, and inclusive education practices in particular.
Exclusion, Alienation and the Sectarian Mind: Critical Education versus Dogmatic Training
Authors: Elmore John M.
Published: March 2014

A consideration of the exclusionary practices and outcomes generated by religious absolutism is perhaps as essential today as it has ever been throughout human history. In this article, the author argues that the exclusionary and anti-dialogical characteristics of religion, which have generated countless atrocities throughout human history, are actually an outcome initially seeded in the exclusion of self – the alienation of man from his full nature. The symptoms of religious alienation supplant the possibility of inclusion on both an individual level, perverting the relationship with ourselves and our fellow man, and on a collective level, diverting the social, political and economic institutions we construct and support with the compulsion of exclusion. Deploying conceptual tools from a range of contributors, including Hegel, Bauer and Feuerbach, this article analyzes these realities. Further, it draws on the writing of Paulo Freire in order to consider the critical role education might play in challenging dogmatic thinking, religious and otherwise, and in counteracting exclusion via the development of individual and collective critical consciousness.
Public Libraries, Citizens and the Democracy
Authors: Blewitt John
Published: March 2014

This essay explores the relationship between the development of public libraries in the context of an increasingly market-dominated economy and marketised society. It argues that although neo-liberalism as a policy goal and practice has taken different forms over time, there are common themes in terms of its emphasis on market values, privatisation, and the support of measures that reduce the role of public funding and the state in the provision of public services. This has led some commentators to express concerns that the meaning and practice of citizenship and democracy is being transformed, managed or otherwise diminished. These concerns are compounded by changes effected by new digital technology. Imbricated with this issue are debates surrounding the future of the public library, and attempts by librarians and others to reinvent and reimagine its purpose. With reference to some innovative initiatives in the USA and Scandinavia, it is suggested that public libraries, through their service and spatial rearticulation, can conceivably help strengthen and revitalise public democracy and the public sphere.
Writing before it was All Shakespeare
Authors: Bell Simon
Published: March 2014

In this paper I argue that short and carefully structured essays can foster risk if they blend unfamiliar format with proper content demand. Students were given a square with 16 lines and 128 words and were asked to rewrite it into an eristic essay of the same format. The project's theoretical basis was short stories' use of scale, suggestion, openers, repeats, subversion; risk; academic writing, reader response. A lot of the essays were daring and different. Interviews showed that some students enjoyed autonomy and risk. But risk is safe if it is safely set into courses. The paper concludes that it is risky to think you empower students by giving them power: they should take it, and not be given it.
Sitagliptin, a DPP-4 Inhibitor, Acutely Inhibits Intestinal Lipoprotein Particle Secretion in Healthy Humans
Authors: Xiao Changting , Dash Satya , Morgantini Cecilia , Patterson Bruce W. , Lewis Gary F.
Published: March 2014

The dipeptidyl peptidase-4 inhibitor sitagliptin, an antidiabetic agent, which lowers blood glucose levels, also reduces postprandial lipid excursion after a mixed meal. The underlying mechanism of this effect, however, is not clear. This study examined the production and clearance of triglyceride-rich lipoprotein particles from the liver and intestine in healthy volunteers in response to a single oral dose of sitagliptin. Using stable isotope tracer techniques and with control of pancreatic hormone levels, the kinetics of lipoprotein particles of intestinal and hepatic origin were measured. Compared with placebo, sitagliptin decreased intestinal lipoprotein concentration by inhibiting particle production, independent of changes in pancreatic hormones, and circulating levels of glucose and free fatty acids. Fractional clearance of particles of both intestinal and hepatic origin, and production of particles of hepatic origin, were not affected. This pleiotropic effect of sitagliptin may explain the reduction in postprandial lipemia seen in clinical trials of this agent and may provide metabolic benefits beyond lowering of glucose levels.
Impact of Acute Hyperglycemia on Myocardial Infarct Size, Area at Risk, and Salvage in Patients With STEMI and the Association With Exenatide Treatment: Results From a Randomized Study
Authors: Lønborg Jacob , Vejlstrup Niels , Kelbæk Henning , Nepper-Christensen Lars , Jørgensen Erik , Helqvist Steffen , Holmvang Lene , Saunamäki Kari , Bøtker Hans Erik , Kim Won Yong , Clemmensen Peter , Treiman Marek , Engstrøm Thomas
Published: March 2014

Hyperglycemia upon hospital admission in patients with ST-segment elevation myocardial infarction (STEMI) occurs frequently and is associated with adverse outcomes. It is, however, unsettled as to whether an elevated blood glucose level is the cause or consequence of increased myocardial damage. In addition, whether the cardioprotective effect of exenatide, a glucose-lowering drug, is dependent on hyperglycemia remains unknown. The objectives of this substudy were to evaluate the association between hyperglycemia and infarct size, myocardial salvage, and area at risk, and to assess the interaction between exenatide and hyperglycemia. A total of 210 STEMI patients were randomized to receive intravenous exenatide or placebo before percutaneous coronary intervention. Hyperglycemia was associated with larger area at risk and infarct size compared with patients with normoglycemia, but the salvage index and infarct size adjusting for area at risk did not differ between the groups. Treatment with exenatide resulted in increased salvage index both among patients with normoglycemia and hyperglycemia. Thus, we conclude that the association between hyperglycemia upon hospital admission and infarct size in STEMI patients is a consequence of a larger myocardial area at risk but not of a reduction in myocardial salvage. Also, cardioprotection by exenatide treatment is independent of glucose levels at hospital admission. Thus, hyperglycemia does not influence the effect of the reperfusion treatment but rather represents a surrogate marker for the severity of risk and injury to the myocardium.
Increased Interaction With Insulin Receptor Substrate 1, a Novel Abnormality in Insulin Resistance and Type 2 Diabetes
Authors: Caruso Michael , Ma Danjun , Msallaty Zaher , Lewis Monique , Seyoum Berhane , Al-janabi Wissam , Diamond Michael , Abou-Samra Abdul B. , Højlund Kurt , Tagett Rebecca , Draghici Sorin , Zhang Xiangmin , Horowitz Jeffrey F. , Yi Zhengping
Published: March 2014

Insulin receptor substrate 1 (IRS1) is a key mediator of insulin signal transduction. Perturbations involving IRS1 complexes may lead to the development of insulin resistance and type 2 diabetes (T2D). Surprisingly little is known about the proteins that interact with IRS1 in humans under health and disease conditions. We used a proteomic approach to assess IRS1 interaction partners in skeletal muscle from lean healthy control subjects (LCs), obese insulin-resistant nondiabetic control subjects (OCs), and participants with T2D before and after insulin infusion. We identified 113 novel endogenous IRS1 interaction partners, which represents the largest IRS1 interactome in humans and provides new targets for studies of IRS1 complexes in various diseases. Furthermore, we generated the first global picture of IRS1 interaction partners in LCs, and how they differ in OCs and T2D patients. Interestingly, dozens of proteins in OCs and/or T2D patients exhibited increased associations with IRS1 compared with LCs under the basal and/or insulin-stimulated conditions, revealing multiple new dysfunctional IRS1 pathways in OCs and T2D patients. This novel abnormality, increased interaction of multiple proteins with IRS1 in obesity and T2D in humans, provides new insights into the molecular mechanism of insulin resistance and identifies new targets for T2D drug development.
Thoracolumbar instrumentation with CT-guided navigation (O-arm) in 270 consecutive patients: accuracy rates and lessons learned
Authors: Rivkin Mark A. , Yocom Steven S.
Published: March 2014

Object

Thoracolumbar instrumentation has experienced a dramatic increase in utilization over the last 2 decades. However, pedicle screw fixation remains a challenging undertaking, with suboptimal placement contributing to postoperative pain, neurological deficit, vascular complications, and return to the operating suite. Image-guided spinal surgery has substantially improved the accuracy rates for these procedures. However, it is not without technical challenges and a learning curve for novice operators. The authors present their experience with the O-arm intraoperative imaging system and share the lessons they learned over nearly 5 years.

Methods

The authors performed a retrospective chart review of 270 consecutive patients who underwent thoracolumbar pedicle screw fixation utilizing the O-arm imaging system in conjunction with StealthStation navigation between April 2009 and September 2013 at a single tertiary care center; 266 of the patients underwent CT scanning on postoperative Day 1 to evaluate hardware placement. The CT scans were interpreted prospectively by 3 neuroradiologists as part of standard work flow and retrospectively by 2 neurosurgeons and a senior resident. Pedicle screws were evaluated for breaches according to the 3-tier classification proposed by Mirza et al.

Results

Of 270 patients, 266 (98.5%) were included in the final analysis based on the presence of a postoperative CT scan. Overall, 1651 pedicle screws were placed in 266 patients and yielded a 5.3% breach rate; 213 thoracic and 1438 lumbosacral pedicle screws were inserted with 6.6% and 5.1% breach rates, respectively. Of the 87 suboptimally placed screws, there were 13 Grade 1, 16 Grade 2, and 12 Grade 3 misses as well as 46 anterolateral or “tip-out” perforations at L-5. Four patients (1.5%) required a return to the operating room for pedicle screw revision, 2 of whom experienced transient radicular symptoms and 2 remained asymptomatic. Interestingly, the pedicle breach rate was higher than anticipated at 13.21% for the 30 patients over the initial 6-month period with the O-arm. After certain modifications to the authors' technique, the subsequent 30 patients experienced a statistically significant decrease in breach rate at 5.6% (p = 0.014).

Conclusions

Image-guided spinal surgery can be a great option in the operating room and provides high pedicle screw accuracy rates. With numerous systems commercially available, it is important to develop a systematic approach regardless of the technology in question. There is a learning curve for surgeons unfamiliar with image guidance that should be recognized and appreciated when transitioning to navigation-assisted spinal surgery. In fact, the authors' experience with a large patient cohort suggests that this learning curve may be more significant than previously reported.
The use of intraoperative navigation for complex upper cervical spine surgery
Authors: Guppy Kern H. , Chakrabarti Indro , Banerjee Amit
Published: March 2014

Imaging guidance using intraoperative CT (O-arm surgical imaging system) combined with a navigation system has been shown to increase accuracy in the placement of spinal instrumentation. The authors describe 4 complex upper cervical spine cases in which the O-arm combined with the StealthStation surgical navigation system was used to accurately place occipital screws, C-1 screws anteriorly and posteriorly, C-2 lateral mass screws, and pedicle screws in C-6. This combination was also used to navigate through complex bony anatomy altered by tumor growth and bony overgrowth. The 4 cases presented are: 1) a developmental deformity case in which the C-1 lateral mass was in the center of the cervical canal causing cord compression; 2) a case of odontoid compression of the spinal cord requiring an odontoidectomy in a patient with cerebral palsy; 3) a case of an en bloc resection of a C2–3 chordoma with instrumentation from the occiput to C-6 and placement of C-1 lateral mass screws anteriorly and posteriorly; and 4) a case of repeat surgery for a non-union at C1–2 with distortion of the anatomy and overgrowth of the bony structure at C-2.
Intraoperative image-guided spinal navigation: technical pitfalls and their avoidance
Authors: Rahmathulla Gazanfar , Nottmeier Eric W. , Pirris Stephen M. , Deen H. Gordon , Pichelmann Mark A.
Published: March 2014

Spinal instrumentation has made significant advances in the last two decades, with transpedicular constructs now widely used in spinal fixation. Pedicle screw constructs are routinely used in thoracolumbar-instrumented fusions, and in recent years, the cervical spine as well. Three-column fixations with pedicle screws provide the most rigid form of posterior stabilization. Surgical landmarks and fluoroscopy have been used routinely for pedicle screw insertion, but a number of studies reveal inaccuracies in placement using these conventional techniques (ranging from 10% to 50%). The ability to combine 3D imaging with intraoperative navigation systems has improved the accuracy and safety of pedicle screw placement, especially in more complex spinal deformities. However, in the authors' experience with image guidance in more than 1500 cases, several potential pitfalls have been identified while using intraoperative spinal navigation that could lead to suboptimal results. This article summarizes the authors' experience with these various pitfalls using spinal navigation, and gives practical tips on their avoidance and management.
Novel placement of cortical bone trajectory screws in previously instrumented pedicles for adjacent-segment lumbar disease using CT image-guided navigation
Authors: Rodriguez Analiz , Neal Matthew T. , Liu Ann , Somasundaram Aravind , Hsu Wesley , Branch Charles L.
Published: March 2014

Object

Symptomatic adjacent-segment lumbar disease (ASLD) after lumbar fusion often requires subsequent surgical intervention. The authors report utilizing cortical bone trajectory (CBT) pedicle screw fixation with intraoperative CT (O-arm) image-guided navigation to stabilize spinal levels in patients with symptomatic ASLD. This unique technique results in the placement of 2 screws in the same pedicle (1 traditional pedicle trajectory and 1 CBT) and obviates the need to remove preexisting instrumentation.

Methods

The records of 5 consecutive patients who underwent lumbar spinal fusion with CBT and posterior interbody grafting for ASLD were retrospectively reviewed. All patients underwent screw trajectory planning with the O-arm in conjunction with the StealthStation navigation system. Basic demographics, operative details, and radiographic and clinical outcomes were obtained.

Results

The average patient age was 69.4 years (range 58–82 years). Four of the 5 surgeries were performed with the Minimal Access Spinal Technologies (MAST) Midline Lumbar Fusion (MIDLF) system. The average operative duration was 218 minutes (range 175–315 minutes). In the entire cohort, 5.5-mm cortical screws were placed in previously instrumented pedicles. The average hospital stay was 2.8 days (range 2–3 days) and there were no surgical complications. All patients had more than 6 months of radiographic and clinical follow-up (range 10–15 months). At last follow-up, all patients reported improved symptoms from their preoperative state. Radiographic follow-up showed Lenke fusion grades of A or B.

Conclusions

The authors present a novel fusion technique that uses CBT pedicle screw fixation in a previously instrumented pedicle with intraoperative O-arm guided navigation. This method obviates the need for hardware removal. This cohort of patients experienced good clinical results. Computed tomography navigation was critical for accurate CBT screw placement at levels where previous traditional pedicle screws were already placed for symptomatic ASLD.
Accuracy of intraoperative computed tomography image-guided surgery in placing pedicle and pelvic screws for primary versus revision spine surgery
Authors: Hsieh Joseph C. , Drazin Doniel , Firempong Alexander O. , Pashman Robert , Johnson J. Patrick , Kim Terrence T.
Published: March 2014

Object

Revision spine surgery, which is challenging due to disrupted anatomy, poor fluoroscopic imaging, and altered tactile feedback, may benefit from CT image-guided surgery (CT-IGS). This study evaluates accuracy of CT-IGS–navigated screws in primary versus revision spine surgery.

Methods

Pedicle and pelvic screws placed with the O-arm in 28 primary (313 screws) and 33 revision (429 screws) cases in which institutional postoperative CT scans were available were retrospectively reviewed for placement accuracy. Screw accuracy was categorized as 1) good (< 1-mm pedicle breach in any direction or “in-out-in” thoracic screws through the lateral thoracic pedicle wall and in the costovertebral joint); 2) fair (1- to 3-mm breach); or 3) poor (> 3-mm breach).

Results

Use of CT-IGS resulted in high rates of good or fair screws for both primary (98.7%) and revision (98.6%) cases. Rates of good or fair screws were comparable for the following regions: C7–T3 at 100% (good or fair) in primary versus 100% (good or fair) in revision; T4–9 at 96.8% versus 100%; T10–L2 at 98.2% versus 99.3%; L3–5 at 100% versus 99.2%; and pelvis at 98.7% versus 98.6%, respectively. On the other hand, revision sacral screws had statistically significantly lower rates of good placement compared with primary (100% primary vs 80.6% revision, p = 0.027). Of these revision sacral screws, 11.1% had poor placement, with bicortical screws extending > 3 mm beyond the anterior cortex. Revision pelvic screws demonstrated the highest rate of fair placement (28%), with the mode of medial breach in all cases directed into the sacral-iliac joint.

Conclusions

In the cervical, thoracic, and lumbar spine, CT-IGS demonstrated comparable accuracy rates for both primary and revision spine surgery. Use of 3D imaging of the bony pedicle anatomy appears to be sufficient for the spine surgeon to overcome the difficulties associated with instrumentation in revision cases. Although the bony structures of sacral pedicles and pelvis are relatively larger, the complexity of local anatomy was not overcome with CT-IGS, and an increased trend toward inaccurate screw placement was demonstrated.
Instrumenting the small thoracic pedicle: the role of intraoperative computed tomography image–guided surgery
Authors: Jeswani Sunil , Drazin Doniel , Hsieh Joseph C. , Shweikeh Faris , Friedman Eric , Pashman Robert , Johnson J. Patrick , Kim Terrence T.
Published: March 2014

Object

Traditionally, instrumentation of thoracic pedicles has been more difficult because of their relatively smaller size. Thoracic pedicles are at risk for violation during surgical instrumentation, as is commonly seen in patients with scoliosis and in women. The laterally based “in-out-in” approach, which technically results in a lateral breach, is sometimes used in small pedicles to decrease the comparative risk of a medial breach with neurological involvement. In this study the authors evaluated the role of CT image–guided surgery in navigating screws in small thoracic pedicles.

Methods

Thoracic (T1–12) pedicle screw placements using the O-arm imaging system (Medtronic Inc.) were evaluated for accuracy with preoperative and postoperative CT. “Small” pedicles were defined as those ≤ 3 mm in the narrowest diameter orthogonal to the long axis of the pedicle on a trajectory entering the vertebral body on preinstrumentation CT. A subset of “very small” pedicles (≤ 2 mm in the narrowest diameter, 13 pedicles) was also analyzed. Screw accuracy was categorized as good (< 1 mm of pedicle breach in any direction or in-out-in screws), fair (1–3 mm of breach), or poor (> 3 mm of breach).

Results

Twenty-one consecutive patients (age range 32–71 years) had large (45 screws) and small (52 screws) thoracic pedicles. The median pedicle diameter was 2.5 mm (range 0.9–3 mm) for small and 3.9 mm (3.1–6.7 mm) for large pedicles. Computed tomography–guided surgical navigation led to accurate screw placement in both small (good 100%, fair 0%, poor 0%) and large (good 96.6%, fair 0%, poor 3.4%) pedicles. Good screw placement in very small or small pedicles occurred with an in-out-in trajectory more often than in large pedicles (large 6.8% vs small 36.5%, p < 0.0005; vs very small 69.2%, p < 0.0001). There were no medial breaches even though 75 of the 97 screws were placed in postmenopausal women, traditionally at higher risk for osteoporosis.

Conclusions

Computed tomography–guided surgical navigation allows for safe, effective, and accurate instrumentation of small (≤ 3 mm) to very small (≤ 2 mm) thoracic pedicles.
Clinical and radiographic outcomes of minimally invasive percutaneous pedicle screw placement with intraoperative CT (O-arm) image guidance navigation
Authors: Kim Terrence T. , Drazin Doniel , Shweikeh Faris , Pashman Robert , Johnson J. Patrick
Published: March 2014

Object

Intraoperative CT image–guided navigation (IGN) has been increasingly incorporated into minimally invasive spine surgery (MIS). The vast improvement in image resolution and virtual real-time images with CT-IGN has proven superiority over traditional fluoroscopic techniques. The authors describe their perioperative MIS technique using the O-arm with navigation, and they report their postoperative experience, accuracy results, and technical aspects.

Methods

A retrospective review of 48 consecutive adult patients undergoing minimally invasive percutaneous posterior spinal fusion with intraoperative CT-IGN between July 2010 and August 2013 at Cedars-Sinai Medical Center was performed. Two surgeons assessed 290 screws in a blinded fashion on intraoperative O-arm images and postoperative CT scans for bony pedicle wall breach. Grade 1 breach was defined to be < 2 mm, Grade 2 breach to be between 2 and 4 mm, and a Grade 3 breach to be > 4 mm. Additionally, anterior vertebral body breach was recorded.

Results

Of 290 pedicle screws placed, 280 (96.6%) were in an acceptable position without cortical wall or anterior breach. Of the 10 breaches (3.4%) 5 were lateral (50%), 4 were medial, and 1 was anterior; 90% of breaches were Grade 1–2 and all medial breaches were Grade 1. The one Grade 3 breach was lateral. No vascular or neurological complications were observed intraoperatively, and no significant postoperative complications were noted. The mean clinical follow-up period was 18 months (range 3–39 months). The overall clinical outcomes, measured using the visual analog scale (back pain scores), were improved significantly postoperatively at 3 months compared with preoperatively (visual analog score 6.35 vs 3.57; p < 0.0001). No revision surgery was performed for screw misplacement or neurological deterioration.

Conclusions

New CT-IGN with the mobile O-arm scanner has increased the accuracy of pedicle screw/instrumentation placement using MIS techniques. The authors' high (96.6%) accuracy rate in MIS compares favorably with historical published accuracy rates for fluoroscopy-based techniques. Additional advantages of CT-IGN over fluoroscopic imaging methods are lower occupational radiation exposure for the surgical team, reduced need for postoperative imaging, and decreased rates of revision surgery. For now, the authors simply conclude that use of intraoperative CT-IGN is safe and accurate.