This book is an open access book. Many scholars have wondered if a non-Western theory of international politics founded on different premises, be it from Asia or from the “Global South,” could ...release international relations from the grip of a Western, “Westphalian” model. This book argues that a Buddhist approach to international relations could provide a genuine alternative. Because of its distinctive philosophical positions and its unique understanding of reality, human nature and political behavior, a Buddhist theory of IR offers a way out of this dilemma, a means for transcending the Westphalian predicament. The author explains this Buddhist IR model, beginning with its philosophical foundations up through its ideas about politics, economics and statecraft.
Abstract Background context Prior studies on the impact of obesity on spine surgery outcomes have focused mostly on lumbar fusions, do not examine lumbar discectomies or decompressions, and have ...shown mixed results regarding complications. Differences in sample sizes and body mass index (BMI) thresholds for the definition of the obese versus comparison cohorts could account for the inconsistencies in the literature. Purpose The purpose of the study was to analyze whether different degrees of obesity influence the complication rates in patients undergoing lumbar spine surgery. Study design/setting This was a retrospective cohort analysis of prospectively collected data using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2010. Patient sample Patients in the de-identified, risk-adjusted, and multi-institutional ACS NSQIP database undergoing lumbar anterior fusion, posterior fusion, transforaminal lumbar interbody fusion/posterior lumbar interbody fusion (TLIF/PLIF), discectomy, or decompression were included. Outcome measures Primary outcome measures were 30-day postsurgical complications, including pulmonary embolism and deep vein thrombosis, death, system-specific complications (wound, pulmonary, urinary, central nervous system, and cardiac), septic complications, and having one or more complications overall. Secondary outcomes were time spent in the operating room, blood transfusions, length of stay, and reoperation within 30 days. Methods Patients undergoing lumbar anterior fusion, posterior fusion, TLIF/PLIF, discectomy, or decompression in the ACS NSQIP, 2005 to 2010, were categorized into four BMI groups: nonobese (18.5–29.9 kg/m2 ), Obese I (30–34.9 kg/m2 ), Obese II (35–39.9 kg/m2 ), and Obese III (greater than or equal to 40 kg/m2 ). Obese I to III patients were compared with patients in the nonobese category using chi-square test and analysis of variance. Multivariate linear/logistic regression models were used to adjust for preoperative risk factors. Results Data were available for 10,387 patients undergoing lumbar surgery. Of these, 4.5% underwent anterior fusion, 17.9% posterior fusion, 6.3% TLIF/PLIF, 40.7% discectomy, and 30.5% decompression. Among all patients, 25.6% were in the Obese I group, 11.5% Obese II, and 6.9% Obese III. On multivariate analysis, Obese I and III had a significantly increased risk of urinary complications, and Obese II and III patients had a significantly increased risk of wound complications. Only Obese III patients, however, had a statistically increased risk of having increased time spent in the operating room, an extended length of stay, pulmonary complications, and having one or more complications (all p<.05). Conclusions Patients with high BMI appear to have higher complication rates after lumbar surgery than patients who are nonobese. However, the complication rates seem to increase substantially for Obese III patients. These patients have longer times spent in the operating room, extended hospitals stays, and an increased risk for wound, urinary, and pulmonary complications and for having at least one or more complications overall. Surgeons should be aware of the increased risk of multiple complications for patients with BMI greater than or equal to 40 kg/m2.
There has been an increasing use of national databases to conduct orthopaedic research. Questions regarding the validity and consistency of these studies have not been fully addressed. The purpose of ...this study was to test for similarity in reported measures between two national databases commonly used for orthopaedic research.
A retrospective cohort study of patients undergoing lumbar spinal fusion procedures during 2009 to 2011 was performed in two national databases: the Nationwide Inpatient Sample and the National Surgical Quality Improvement Program. Demographic characteristics, comorbidities, and inpatient adverse events were directly compared between databases.
The total numbers of patients included were 144,098 from the Nationwide Inpatient Sample and 8434 from the National Surgical Quality Improvement Program. There were only small differences in demographic characteristics between the two databases. There were large differences between databases in the rates at which specific comorbidities were documented. Non-morbid obesity was documented at rates of 9.33% in the Nationwide Inpatient Sample and 36.93% in the National Surgical Quality Improvement Program (relative risk, 0.25; p < 0.05). Peripheral vascular disease was documented at rates of 2.35% in the Nationwide Inpatient Sample and 0.60% in the National Surgical Quality Improvement Program (relative risk, 3.89; p < 0.05). Similarly, there were large differences between databases in the rates at which specific inpatient adverse events were documented. Sepsis was documented at rates of 0.38% in the Nationwide Inpatient Sample and 0.81% in the National Surgical Quality Improvement Program (relative risk, 0.47; p < 0.05). Acute kidney injury was documented at rates of 1.79% in the Nationwide Inpatient Sample and 0.21% in the National Surgical Quality Improvement Program (relative risk, 8.54; p < 0.05).
As database studies become more prevalent in orthopaedic surgery, authors, reviewers, and readers should view these studies with caution. This study shows that two commonly used databases can identify demographically similar patients undergoing a common orthopaedic procedure; however, the databases document markedly different rates of comorbidities and inpatient adverse events. The differences are likely the result of the very different mechanisms through which the databases collect their comorbidity and adverse event data. Findings highlight concerns regarding the validity of orthopaedic database research.
A retrospective review of data collected prospectively by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).
The aim of this study was to investigate the ...association between preoperative hypoalbuminemia, a marker for malnutrition, and complications during the 30 days following posterior lumbar fusion surgery.
Malnutrition is a potentially modifiable risk factor that may contribute to complications following spinal surgery. Although prior studies have identified associations between malnutrition, delayed wound healing, and surgical site infection (SSI), the evidence for such a relationship within spine surgery is mixed.
Patients who underwent posterior lumbar spinal fusion of one to three levels as part of the ACS-NSQIP were identified. Patients without preoperative serum albumin concentration were excluded. Outcomes were compared between patients with and without hypoalbuminemia (defined as serum albumin concentration <3.5 g/dL). All comparisons were adjusted for baseline differences between populations.
Four thousand three hundred ten patients were included. The prevalence of hypoalbuminemia was 4.8%. In comparison to patients with normal albumin concentration, patients with hypoalbuminemia had a higher risk for occurrence of wound dehiscence 1.5% vs. 0.2%, adjusted relative risk (RR) = 5.8, P = 0.006, SSI (5.4% vs. 1.7%, adjusted RR = 2.3, P = 0.010), and urinary tract infection (5.4% vs. 1.5%, adjusted RR = 2.5, P = 0.005). Similarly, patients with hypoalbuminemia had a higher risk for unplanned hospital readmission within 30 days of surgery (11.7% vs. 5.4%, RR = 1.8, P < 0.001). Finally, patients with hypoalbuminemia had a longer mean inpatient stay (5.2 vs. 3.7 days, RR = 1.2, P < 0.001).
The present study suggests that malnutrition is an independent risk factor for infectious and wound complications following posterior lumbar fusion. Malnutrition was also associated with an increased length of stay and readmission. Future studies should evaluate methods of correcting malnutrition before lumbar spinal surgery. Such efforts have the potential to meaningfully decrease the rates of adverse events following this procedure.
3.
Structured Abstract Background Context Lateral lumbar interbody fusion (LLIF) is a frequently utilized technique for the treatment of lumbar pathology. Despite its overall success, LLIF has been ...associated with a unique set of complications. However, there has been inconsistent evidence regarding the complication rate of this approach. Purpose To perform a systematic review analyzing the rates of medical and surgical complications associated with LLIF. Study Design Systematic Review Patient Sample 6819 patients who underwent LLIF reported in clinical studies through June 2016. Outcome Measures Frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and musculoskeletal/spine (MSK) categories. Methods This systematic review was performed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies that identified rates of any complication following LLIF procedures were obtained from PubMed, MEDLINE, and EMBASE databases. Articles were excluded if they did not report complications, presented mixed complication data from other procedures, or were characterized as single case reports, reviews, or case series containing less than 10 patients. The primary outcome was frequency of complications within cardiac, vascular, pulmonary, urologic, gastrointestinal, transient neurologic, persistent neurologic, and musculoskeletal/spine (MSK) categories. All rates of complications were based on the sample sizes of studies that mentioned the respective complications. The authors report no conflicts of interest directly or indirectly related to this work, and have not received any funds in support of this work. Results A total of 2232 articles were identified. Following screening of title, abstract, and full text availability, 63 articles were included in the review. There were a total 6819 patients with 11325 levels fused. The rate of complications for the categories included were as follows: wound (1.38%; 95% confidence interval CI=1.00-1.85%), cardiac (1.86%; CI=1.33-2.52%), vascular (0.81%; CI=0.44-1.36%), pulmonary (1.47; CI=0.95-2.16%), gastrointestinal (1.38%; CI=1.00-1.87%), urologic (0.93%; CI=0.55-1.47%), transient neurologic (36.07%; CI=34.74-37.41%), persistent neurologic (3.98%; CI=3.42-4.60%), and MSK/Spine (9.22%; CI=8.28-10.23%). Concluson The current study is the first to comprehensively analyze the complication profile for LLIFs. The most significant reported complications were transient neurologic in nature. However, persistent neurologic complications occurred at a much lower rate, bringing into question the significance of transient symptoms beyond the immediate postoperative period. Through this analysis of complication profiles, surgeons can better understand the risks and expectations for patients following LLIF procedures.
The Centers for Medicare & Medicaid Services (CMS)'s Bundled Payments for Care Improvement (BPCI) program provides a set payment for the provision of primary total joint arthroplasty (TJA) care ...regardless of age and risk factors. Published literature indicates that the cost of care per episode of TJA increases with age. We examined the implication of this relationship and the effect of projected changes of age demographics on our center's BPCI experience.
A retrospective review of prospectively collected data on 1,662 Medicare BPCI patients undergoing primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) from 2013 to 2016 at a single orthopaedic institution was performed. The relationship between age and cost of care was first determined in our analysis of our BPCI experience. We then performed a cost analysis by age group with respect to our institution's profit or loss per episode of care. A forecast for shifting age demographics in our region, modeled by the U.S. Census Bureau's Federal-State Cooperative for Population Estimates (FSCPE) and Projections (FSCPP), was used to evaluate the financial implications for our BPCI program.
Our institution sustains a significant loss of $1,934 (p < 0.001) per case for patients 85 to 99 years of age, which is offset by profits associated with treating patients in younger age groups. This age group (85 to 99 years of age) will double by the year 2040 in our region, whereas the youngest age group (65 to 69 years of age) is projected to marginally increase by 12%. The average cost of care per primary TJA will rise because of the predicted shifting age demographics, compounded by an estimated 3% inflation rate. Utilizing the current BPCI reimbursement rate, we project an inflection point of declining profits after the year 2030 with the given projections for our regional population.
The regional population served by our institution is aging. This shift will lead to an increased cost of care and diminishing profits for TJA after 2030. The CMS's BPCI initiative and novel alternative payment models (APMs) should consider age as a modifier for reimbursement to incentivize care for the vulnerable and older age groups.
The findings of the present study are clinically relevant for decision-making regarding the allocation of resources in the setting of an aging population.
Text-based patient medical records are a vital resource in medical research. In order to preserve patient confidentiality, however, the U.S. Health Insurance Portability and Accountability Act ...(HIPAA) requires that protected health information (PHI) be removed from medical records before they can be disseminated. Manual de-identification of large medical record databases is prohibitively expensive, time-consuming and prone to error, necessitating automatic methods for large-scale, automated de-identification.
We describe an automated Perl-based de-identification software package that is generally usable on most free-text medical records, e.g., nursing notes, discharge summaries, X-ray reports, etc. The software uses lexical look-up tables, regular expressions, and simple heuristics to locate both HIPAA PHI, and an extended PHI set that includes doctors' names and years of dates. To develop the de-identification approach, we assembled a gold standard corpus of re-identified nursing notes with real PHI replaced by realistic surrogate information. This corpus consists of 2,434 nursing notes containing 334,000 words and a total of 1,779 instances of PHI taken from 163 randomly selected patient records. This gold standard corpus was used to refine the algorithm and measure its sensitivity. To test the algorithm on data not used in its development, we constructed a second test corpus of 1,836 nursing notes containing 296,400 words. The algorithm's false negative rate was evaluated using this test corpus.
Performance evaluation of the de-identification software on the development corpus yielded an overall recall of 0.967, precision value of 0.749, and fallout value of approximately 0.002. On the test corpus, a total of 90 instances of false negatives were found, or 27 per 100,000 word count, with an estimated recall of 0.943. Only one full date and one age over 89 were missed. No patient names were missed in either corpus.
We have developed a pattern-matching de-identification system based on dictionary look-ups, regular expressions, and heuristics. Evaluation based on two different sets of nursing notes collected from a U.S. hospital suggests that, in terms of recall, the software out-performs a single human de-identifier (0.81) and performs at least as well as a consensus of two human de-identifiers (0.94). The system is currently tuned to de-identify PHI in nursing notes and discharge summaries but is sufficiently generalized and can be customized to handle text files of any format. Although the accuracy of the algorithm is high, it is probably insufficient to be used to publicly disseminate medical data. The open-source de-identification software and the gold standard re-identified corpus of medical records have therefore been made available to researchers via the PhysioNet website to encourage improvements in the algorithm.
No study has yet assessed the efficacy of virtual reality (VR) simulation for teaching orthopedic surgery residents. In this blinded, randomized, and controlled trial, we asked if the use of VR ...simulation improved postgraduate year (PGY)-1 orthopedic residents’ performance in cadaver total hip arthroplasty and if the use of VR simulation had a preferentially beneficial effect on specific aspects of surgical skills or knowledge.
Fourteen PGY-1 orthopedic residents completed a written pretest and a single cadaver total hip arthroplasty (THA) to establish baseline levels of knowledge and surgical ability before 7 were randomized to VR-THA simulation. All participants then completed a second cadaver THA and retook the test to assess for score improvements. The primary outcomes were improvement in test and cadaver THA scores.
There was no significant difference in the improvement in test scores between the VR and control groups (P = .078). In multivariate regression analysis, the VR cohort demonstrated a significant improvement in overall cadaver THA scores (P = .048). The VR cohort demonstrated greater improvement in each specific score category compared with the control group, but this trend was only statistically significant for technical performance (P = .009).
VR-simulation improves PGY-1 resident surgical skills but has no significant effect on medical knowledge. The most significant improvement was seen in technical skills. We anticipate that VR simulation will become an indispensable part of orthopedic surgical education, but further study is needed to determine how best to use VR simulation within a comprehensive curriculum.
Level 1.
Intraoperative tourniquet use in total knee arthroplasty (TKA) is a common practice which may improve visualization of the surgical field and reduce blood loss. However, the safety and efficacy ...associated with tourniquet use continues to be a subject of debate among orthopedic surgeons. The primary purpose of this study is to evaluate the effects of tourniquet use on pain and opioid consumption after TKA.
This is a multicenter randomized controlled trial among patients undergoing TKA. Patients were preoperatively randomized to undergo TKA with or without the use of an intraoperative tourniquet. Frequency distributions, means, and standard deviations were used to describe baseline patient demographics (age, gender, race, body mass index, smoking status), length of stay, surgical factors, visual analog scale pain scores, and opioid consumption in morphine milligram equivalents.
A total of 327 patients were included in this study, with 166 patients undergoing TKA without a tourniquet and 161 patients with a tourniquet. A statistically significant difference was found in surgical time (97.87 vs 92.98 minutes; P = .05), whereas none was found for length of stay (1.73 vs 1.70 days; P = .87), postop visual analog scale pain scores (1.73 vs 1.70; P = .87), inpatient opioid consumption (19.84 vs 19.27 morphine milligram equivalents; P = .74), or outpatient opioid consumption between the tourniquet-less and tourniquet cohorts, respectively. There were no readmissions in either cohort during the 90-day episode of care.
Utilization of a tourniquet during TKA has minimal impact on postoperative pain scores and opioid consumption when compared with patients who underwent TKA without a tourniquet.
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