Search

In this chapter, using a combination of the expectation-confirmation theory (ECT) and the latent variable model, the authors have analyzed what factors contribute to one's intention to continue usage with conformation, performance expectancy, and satisfaction. Based on a sample of 678 smart wearable users, collected from Northern India, the authors have used structural equation modelling (Smart PLS4) and identified the impact of satisfaction post-adoption technology, willingness to pay a premium price, and health information accuracy on the continuing intention of smart wearable users. According to the findings, consumer satisfaction, health information accuracy, and willingness to pay the premium price are key variables that have a substantial impact on the long-term purpose to repurchase and use smart wearables. This study has many implications for smartwatch manufacturers and designers looking to increase users' intent to continue using their products.

To assess whether a shorter length of stay (LOS) is associated with a higher risk of readmission among newborns with neonatal abstinence syndrome (NAS) and examine the risk, causes, and characteristics associated with readmissions among newborns with NAS, using a longitudinally linked population-based database.Our study sample included full-term singletons with NAS (n = 4,547) and without NAS (n = 327,836), born in Massachusetts during 2011-2017. We used log-binomial regression models to estimate the crude risk ratios (cRRs) and adjusted RRs with 95% confidence intervals (CI) of the association between LOS and readmissions, controlling for maternal age, race/ethnicity, education, marital status, insurance, method of delivery, birthweight, adequacy of prenatal care, smoking, and abnormal conditions of newborn.Compared with infants without NAS, infants with NAS had a non-significantly higher risk of readmission within 2-42 days (2.8% vs. 2.5%; p = 0.17) and a significantly higher risk of readmission within 43-182 days (2.7% vs. 1.8%; p 0.001). The risk of readmission within 2-42 days was significantly higher among infants with NAS with a LOS of 0-6 days compared to a LOS of 14-20 days (reference group) (aRR: 2.1; 95% CI: 1.2-3.5). No significant differences in readmission rates between 43 and 182 days were observed across LOS categories.Among infants with NAS, a LOS of 0-6 days was associated with a significantly higher risk of readmission within 2-42 days of discharge compared to a longer LOS.

In this study, we examined the influence of users’ experiences with the unified payments interface (UPI) system on the usage behavior of central bank digital currency (CBDC) in India. Our research developed a novel conceptual framework that investigated the relationships between technology, cognitive factors, and behavioral intentions towards CBDC use. The framework integrated UPI usage experience as a moderator within existing models of behavioral intentions and use behaviors. We collected data through a survey conducted in major Indian cities during the pilot launch of CBDC. By utilizing a partial least squares structural equation model (PLS-SEM), we analyzed the proposed model and the relationships between the constructs. Our findings revealed the significant impact of hedonic motivation and performance expectancy on users’ behavioral intentions towards CBDC. Social influence also played a significant role in CBDC usage. Furthermore, we identified that prior UPI usage negatively moderated the relationship between performance expectancy and behavioral intention, as well as the relationship between social influence and use behavior. However, prior UPI usage did not significantly moderate the relationships between perceived risk, hedonic motivation, behavioral intention, and use behavior. These findings contribute to our understanding of the factors influencing CBDC adoption and usage behavior in India.

Owing to the unique properties of ZnO nanoparticles attracted the attention of researchers to work in fluid heating and cooling industries. These particles have fine thermal conductivity (TC), resistive to corrosion, antibacterial behavior, less costly and ease in availability. ZnO based nanofluids were also used in various heat transfer applications. In this article, different characterization techniques of ZnO nanopowder have been studied. These techniques are Field Emission Scanning Electron Microscopy (FESEM), Energy Dispersive Analysis of X-rays (EDAX), X-ray diffraction (XRD) and RAMAN spectroscopy. FESEM was used to find topographical surface details with morphological behaviour of examined nanoparticles. Detailed FESEM images were shown at different magnifications of measurement. EDAX gave the elemental analysis and proof of purity of sample. XRD depicted the information about crystallographic planes of mentioned nanoparticles through Miller indices. Good chemical and structural properties of ZnO nanoparticles were found through different studied characterization techniques. Thus, ZnO nanoparticles based nanofluids were also considered as potential candidate in various thermo-fludic industries.

OBJECTIVE Previous reports of rod fracture (RF) in adult spinal deformity are limited by heterogeneous cohorts, low follow-up rates, and relatively short follow-up durations. Since the majority of RFs present > 2 years after surgery, true occurrence and revision rates remain unclear. The objectives of this study were to better understand the risk factors for RF and assess its occurrence and revision rates following primary thoracolumbar fusions to the sacrum/pelvis for adult symptomatic lumbar scoliosis (ASLS) in a prospective series with long-term follow-up. METHODS Patient records were obtained from the Adult Symptomatic Lumbar Scoliosis–1 (ASLS-1) database, an NIH-sponsored multicenter, prospective study. Inclusion criteria were as follows: patients aged 40–80 years undergoing primary surgeries for ASLS (Cobb angle ≥ 30° and Oswestry Disability Index ≥ 20 or Scoliosis Research Society-22r ≤ 4.0 in pain, function, and/or self-image) with instrumented fusion of ≥ 7 levels that included the sacrum/pelvis. Patients with and without RF were compared to assess risk factors for RF and revision surgery. RESULTS Inclusion criteria were met by 160 patients (median age 62 years, IQR 55.7–67.9 years). At a median follow-up of 5.1 years (IQR 3.8–6.6 years), there were 92 RFs in 62 patients (38.8%). The median time to RF was 3.0 years (IQR 1.9–4.54 years), and 73% occurred > 2 years following surgery. Based on Kaplan-Meier analyses, estimated RF rates at 2, 4, 5, and 8 years after surgery were 11%, 24%, 35%, and 49%, respectively. Baseline radiographic, clinical, and demographic characteristics were similar between patients with and without RF. In Cox regression models, greater postoperative pelvic tilt (HR 1.895, 95% CI 1.196–3.002, p = 0.0065) and greater estimated blood loss (HR 1.02, 95% CI 1.005–1.036, p = 0.0088) were associated with increased risk of RF. Thirty-eight patients (61% of all RFs) underwent revision surgery. Bilateral RF was predictive of revision surgery (HR 3.52, 95% CI 1.8–6.9, p = 0.0002), while patients with unilateral nondisplaced RFs were less likely to require revision (HR 0.39, 95% CI 0.18–0.84, p = 0.016). CONCLUSIONS This study provides what is to the authors’ knowledge the highest-quality data to date on RF rates following ASLS surgery. At a median follow-up of 5.1 years, 38.8% of patients had at least one RF. Estimated RF rates at 2, 4, 5, and 8 years after surgery were 11%, 24%, 35%, and 49%, respectively. Greater estimated blood loss and postoperative pelvic tilt were significant risk factors for RF. These findings emphasize the importance of long-term follow-up to realize the true prevalence and cumulative incidence of RF.

Objective To examine associations of maternal primary language with neonatal intensive care unit (NICU) outcomes (mother's milk at discharge, necrotizing enterocolitis [NEC], late-onset sepsis, weight gain) DESIGN: We performed a retrospective cohort study of mother-infant dyads ( Results Among 1402 mothers, 85% spoke English, 7% spoke Spanish, and 7% spoke another language. Compared to English, infants with Spanish-speaking mothers had slower growth (-0.34 z-score units [-0.58, -0.10]). Infants with other non-English-speaking mothers had increased mother's milk at discharge (aOR 1.48 [1.18, 1.85]), NEC (aOR 1.43 [1.05, 1.95]), late-onset sepsis (aOR 2.84) [1.67, 4.83] and slower growth (-0.17 z-score units [-0.29, -0.05]). Conclusions After adjustments, preterm infants with non-English-speaking mothers had worse outcomes than infants with English-speaking mothers.

Objective We leveraged the Massachusetts perinatal quality collaborative (PQC) to address the COVID-19 pandemic. Our goals were to: (1) implement perinatal practices thought to reduce mother-to-infant SARS-CoV-2 transmission while limiting disruption of health-promoting practices and (2) do so without inequities attributable to race/ethnicity, language status, and social vulnerability. Methods Main outcomes were cesarean and preterm delivery, rooming-in, and breastfeeding. We examined changes over time overall and according to race/ethnicity, language status, and social vulnerability from 03/20-07/20 at 11 hospitals. Results Of 255 mothers with SARS-CoV-2, 67% were black or Hispanic and 47% were non-English speaking. Cesarean decreased (49% to 35%), while rooming-in (55% to 86%) and breastfeeding (53% to 72%) increased. These changes did not differ by race/ethnicity, language, or social vulnerability. Conclusions Leveraging the Massachusetts PQC led to rapid changes in perinatal care during the COVID-19 crisis in a short time, representing a novel use of statewide PQC structures.

OBJECTIVE The goal of this study was to assess the conversion rate from baseline cervical alignment to postoperative cervical deformity (CD) and the corresponding proximal junctional kyphosis (PJK) rate in patients undergoing thoracolumbar adult spinal deformity (ASD) surgery. METHODS The operative records of patients with ASD with complete radiographic data beginning at baseline up to 3 years were included. Patients with no baseline CD were postoperatively stratified by Ames CD criteria (T1 slope–cervical lordosis mismatch [TS-CL] > 20°, cervical sagittal vertical axis [cSVA] > 40 mm), where CD was defined as fulfilling one or more of the Ames criteria. Severe CD was defined as TS-CL > 30° or cSVA > 60 mm. Follow-up intervals were established after ASD surgery, with 6 weeks postoperatively defined as early; 6 weeks–1 year as intermediate; 1–2 years as late; and 2–3 years as long-term. Descriptive analyses and McNemar tests identified the CD conversion rate, PJK rate (< −10° change in uppermost instrumented vertebra and the superior endplate of the vertebra 2 levels superior to the uppermost instrumented vertebra), and specific alignment parameters that converted. RESULTS Two hundred sixty-six patients who underwent ASD surgery (mean age 59.7 years, 77.4% female) met the inclusion criteria; 103 of these converted postoperatively, and the remaining 163 did not meet conversion criteria. Thirty-eight patients converted to CD early, 26 converted at the intermediate time point, 29 converted late, and 10 converted in the long-term. At conversion, the early group had the highest mean TS-CL at 25.4° ± 8.5° and the highest mean cSVA at 33.6 mm—both higher than any other conversion group. The long-term group had the highest mean C2–7 angle at 19.7° and the highest rate of PJK compared to other groups (p = 0.180). The early group had the highest rate of conversion to severe CD, with 9 of 38 patients having severe TS-CL and only 1 patient per group converting to severe cSVA. Seven patients progressed from having only malaligned TS-CL at baseline (with normal cSVA) to CD with both malaligned TS-CL and cSVA by 6 weeks. Conversely, only 2 patients progressed from malaligned cSVA to both malaligned cSVA and TS-CL. By 1 year, the former number increased from 7 to 26 patients, and the latter increased from 2 to 20 patients. The revision rate was highest in the intermediate group at 48.0%, versus the early group at 19.2%, late group at 27.3%, and long-term group at 20% (p = 0.128). A higher pelvic incidence–lumbar lordosis mismatch, lower thoracic kyphosis, and a higher thoracic kyphosis apex immediately postoperatively significantly predicted earlier rather than later conversion (all p < 0.05). Baseline lumbar lordosis, pelvic tilt, and sacral slope were not significant predictors. CONCLUSIONS Patients with ASD with normative cervical alignment who converted to CD after thoracolumbar surgery had varying radiographic findings based on timing of conversion. Although the highest number of patients converted within 6 weeks postoperatively, patients who converted in the late or long-term follow-up intervals had higher rates of concurrent PJK and greater radiographic progression.

Three-column osteotomies (3COs), usually in the form of pedicle subtraction or vertebral column resection, have become common in adult spinal deformity surgery. Although a powerful tool for deformity correction, 3COs can increase the risks of perioperative morbidity.Operative patients with adult spinal deformity (Cobb angle of20°, sagittal vertical axis [SVA] of5 cm, pelvic tilt of25°, and/or thoracic kyphosis of60°) with available baseline and 2-year radiographic and health-related quality-of-life (HRQoL) data were included. Patients were stratified into 2 groups by surgical year: Group I (2008 to 2013) and Group II (2014 to 2018). Patients with 3COs were then isolated for outcomes analysis. Severe sagittal deformity was defined by an SVA of9.5 cm. Best clinical outcome (BCO) was defined as an Oswestry Disability Index (ODI) of15 and Scoliosis Research Society (SRS)-22 of4.5. Multivariable regression analyses were used to assess differences in surgical, radiographic, and clinical parameters.Seven hundred and fifty-two patients with adult spinal deformity met the inclusion criteria, and 138 patients underwent a 3CO. Controlling for baseline SVA, PI-LL (pelvic incidence minus lumbar lordosis), revision status, age, and Charlson Comorbidity Index (CCI), Group II was less likely than Group I to have a 3CO (21% versus 31%; odds ratio [OR] = 0.6; 95% confidence interval [CI] = 0.4 to 0.97) and more likely to have an anterior lumbar interbody fusion (ALIF; OR = 1.6; 95% CI = 1.3 to 2.3) and a lateral lumbar interbody fusion (LLIF; OR = 3.8; 95% CI = 2.3 to 6.2). Adjusted analyses showed that Group II had a higher likelihood of supplemental rod usage (OR = 21.8; 95% CI = 7.8 to 61) and a lower likelihood of proximal junctional failure (PJF; OR = 0.23; 95% CI = 0.07 to 0.76) and overall hardware complications by 2 years (OR = 0.28; 95% CI = 0.1 to 0.8). In an adjusted analysis, Group II had a higher likelihood of titanium rod usage (OR = 2.7; 95% CI = 1.03 to 7.2). Group II had a lower 2-year ODI and higher scores on Short Form (SF)-36 components and SRS-22 total (p0.05 for all). Controlling for baseline ODI, Group II was more likely to reach the BCO for the ODI (OR = 2.8; 95% CI = 1.2 to 6.4) and the SRS-22 total score (OR = 4.6; 95% CI = 1.3 to 16).Over a 10-year period, the rates of 3CO usage declined, including in cases of severe deformity, with an increase in the usage of PJF prophylaxis. A better understanding of the utility of 3CO, along with a greater implementation of preventive measures, has led to a decrease in complications and PJF and a significant improvement in patient-reported outcome measures.Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.

Identify factors associated with the need for pharmacologic therapy (PT) among opioid exposed newborn (OENs). Retrospective analysis of a statewide database of OENs from 2017 through 2019. Multivariable mixed-effects logistic regression modeled the association of maternal characteristics, infant characteristics, and family engagement practices on the receipt of PT. Of 2098 OENs, 44.8% required PT for NOWS. Higher odds of PT were associated with in-utero exposure to medication treatment for opioid use disorder (MOUD) and non-prescribed opioids in addition to MOUD; nicotine, benzodiazepines, SSRIs; male; out-born infants and mother’s ineligibility to provide breast-milk. Lower odds were associated with increasing birth year, skin-to-skin (STS) care, and rooming-in. Male, out-born infants exposed to MOUD with additional non-prescribed opioids, nicotine, benzodiazepines and SSSRIs with mothers ineligible to provide breast-milk were more likely to require PT, while modifiable care practices including STS care, and rooming-in decreased the likelihood of PT.

Technological developments are continuously growing to improve the efficiency of thermal systems on the demand of present era. To get rid of the scientists and engineers from traditional heat transfer intensification methods and to miniaturize thermal transport devices, novel and innovative techniques are obligatory. In this whole drive, the effective tube geometries and efficient working fluids perform vital role in the betterment of heat exchange devices. Geometrical argumentations/surface modifications impose on smooth tubes are called as enhanced tubes. These tubes contribute towards high rate of heat transfer by reducing the formation of boundary layer near the wall surfaces of the tube. Also, nanofluids with superior thermo-physical properties compared to conventional fluids also assist the rate of heat exchange in various heat transfer applications. This article begins with the introduction of enhanced tubes and nanofluids and followed by overview of nanofluid synthesis and different tube geometries. An attempt has been made to summarize last decade research contributions in the field of forced convection heat transfer and flow characteristics (HTFC) with employing the combined effect of enhanced tubes and nanofluids. Additional heat transfer enhancement techniques (swirl flow devices, magnetic field, agitation, rotation and pulsation) brace with present ones, are also discreetly deliberated. Proposed correlations by authors are also represented which shows the good agreement with experimental data. Important findings and outcomes from reviewed studies are compiled in discussion section. A number of suggestions and guidelines are highlighted to intensify the heat transfer rate as well as to mitigate the effects of pressure losses in fluid flow pipes.

Opioid use disorder and neonatal abstinence syndrome (NAS) increased in Massachusetts from 1999 to 2013 (1,2). In response, in 2016, the state passed a law requiring birth hospitals to report the number of newborns who were exposed to controlled substances to the Massachusetts Department of Public Health (MDPH)* by mandating monthly reporting of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic codes related to maternal dependence on opioids (F11.20) or benzodiazepines (F13.20) and to newborns affected by maternal use of drugs of addiction (P04.49) or experiencing withdrawal symptoms from maternal drugs of addiction (P96.1) separately.† MDPH uses these same codes for monthly, real-time crude estimates of NAS and uses P96.1 alone for official NAS state reporting.§ MDPH requested CDC's assistance in evaluating the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of either maternal or newborn codes to identify substance-exposed newborns, and of newborn exposure codes (both exposure [P04.49] or withdrawal [P96.1]) and the newborn code for withdrawal alone (P96.1) to identify infants with NAS cases related to three exposure scenarios: 1) opioids, 2) opioids or benzodiazepines, and 3) any controlled substance. Confirmed diagnoses of substance exposure and NAS abstracted from linked clinical records for 1,123 infants born in 2017 and their birth mothers were considered the diagnostic standard and were compared against hospital-reported ICD-10-CM codes. For identifying substance-exposed newborns across the three exposure scenarios, the newborn exposure codes had higher sensitivity (range = 31%-61%) than did maternal drug dependence codes (range = 16%-41%), but both sets of codes had high PPV (≥74%). For identifying NAS, for all exposure scenarios, the sensitivity for either newborn code (P04.49 or P96.1) was ≥92% and the PPV was ≥64%; for P96.1 alone the sensitivity was ≥79% and the PPV was ≥92% for all scenarios. Whereas ICD-10-CM codes are effective for NAS surveillance in Massachusetts, they should be applied cautiously for substance-exposed newborn surveillance. Surveillance for substance-exposed newborns using ICD-10-CM codes might be improved by increasing the use of validated substance-use screening tools and standardized facility protocols and improving communication between patients and maternal health and infant health care providers.

Quantify associations of human milk feeding with in-hospital growth and examine differences by human milk type (maternal or donor). We included infants born

STUDY DESIGN Retrospective analysis of a multicenter prospective adult spinal deformity (ASD) database. OBJECTIVE Quantify postoperative improvements in pain, function, mental health, and self-image for different ASD types. SUMMARY OF BACKGROUND DATA Medical providers are commonly requested to counsel patients on anticipated improvements in specific health domains including pain, function, and self-image following surgery. ASD is a heterogeneous condition; therefore, health domain improvements may vary according to deformity type. Few studies have quantified outcomes for specific ASD types. METHODS Surgically treated ASD patients (≥4 levels fused) prospectively enrolled into a multicenter database, minimum 2-year follow-up, were categorized into ASD types according to Scoliosis Research Society-Schwab ASD classification (THORACIC, LUMBAR, DOUBLE, SAGITTAL, MIXED). Demographic, radiographic, operative, and patient reported outcome measures (NRS back and leg pain, SRS-22r, SF-36) data were evaluated. Preoperative and last postoperative values for pain, physical and social function, mental health, and self-image were evaluated, improvements in each domain were quantified, and domain scores compared to generational normative values. Postoperative improvements were also calculated for three age cohorts ( 65 yr) within each deformity type. RESULTS 359 of 564 patients eligible for study (mean age 57.9 yr, mean scoliosis 43.4°, mean SVA 63.3 mm, mean 11.7 levels fused) had ≥2 yr follow-up. Domain improvements for the entire ASD population were 45.1% for back pain, 41.3% for leg pain, 27.1% for physical function, 35.9% for social function, 62.0% for self-image, and 22.6% for mental health (P

The transfer of heat energy between fluids is frequently used in various processes in industries. The subject of potential heat energy enhancement is great attention in research. With increase in thermal conductivity of fluid, the efficiency of heat transfer in machines can be improved. In this research work, a comparative study is carried out to investigate the effect of Al2O3 Nanofluid on the thermal conductivity with distilled water. KD2 pro thermal property analyzer is used in this work to measure the thermal conductivity. The Al2O3 nanoparticles of the nanofluid have been characterized by using Scanning Electron Microscope, Transmission Electron Microscope, UV-VIS-NIR. Experimentally, it is found that maximum enhancement in thermal conductivity was 8.7% at 80 °C of 0.1 wt % concentration.

BACKGROUND AND OBJECTIVE Methadone and morphine are commonly administered medications for neonatal opioid withdrawal syndrome (NOWS). Infants are increasingly treated with as-needed or “pro re nata” (PRN) medication. The optimal pharmacologic agent for PRN treatment of NOWS has not been examined. This study’s objective is to compare NOWS hospital outcomes between infants treated with PRN methadone versus morphine. METHODS We performed a retrospective cohort study of infants pharmacologically treated for NOWS across 4 Massachusetts hospitals between January 2018 and February 2021. Infants born ≥36 weeks gestation with prenatal opioid exposure treated with PRN methadone or morphine were included. Mixed effects logistic and linear regression models were employed to evaluate differences in transition rates to scheduled dosing, length of stay, and number of PRN doses administered depending on PRN treatment agent. RESULTS There were 86 infants in the methadone group and 52 in the morphine group. There were no significant differences in NOWS hospital outcomes between groups in adjusted models: transition to scheduled dosing (methadone 31.6% vs morphine 28.6%, adjusted odds ratio 1.21, 95% confidence interval [CI] 0.87–1.19), mean length of stay (methadone 15.5 vs morphine 14.3 days, adjusted risk ratio 1.06, 95% CI 0.80–1.41), and the mean number of PRN doses (methadone 2.3 vs morphine 3.4, adjusted risk ratio 0.65, 95% CI 0.41–1.02). There was an association with nonpharmacologic care practices and improved NOWS hospital outcomes. CONCLUSIONS There were no significant differences in NOWS hospitalization outcomes based on pharmacologic agent type; nonpharmacologic care practices were most strongly associated with improved NOWS hospitalization outcomes.

CONTEXT Racial/ethnic inequities are well documented in both maternal-infant health and substance use disorder treatment outcomes. OBJECTIVE To systematically review research on maternal-infant dyads affected by opioid use disorder (OUD) to evaluate for racial/ethnic disparities in health utilization or outcomes and critically assess the reporting and inclusion of race/ethnicity data. DATA SOURCES Peer-reviewed literature in MEDLINE, Embase, and Web of Science from 2000 to 2020. STUDY SELECTION Research reporting health utilization and outcomes data on dyads affected by OUD during pregnancy through the infant’s first birthday. DATA EXTRACTION We extracted data on race/ethnicity, study exposures/outcomes, how race/ethnicity data were analyzed, how authors discussed findings associated with race/ethnicity, and whether racism was mentioned as an explanation for findings. RESULTS Of 2023 articles reviewed, 152 quantitative and 17 qualitative studies were included. Among quantitative studies, 66% examined infant outcomes (n = 101). Three articles explicitly focused on evaluating racial/ethnic differences among dyads. Among quantitative studies, 112 mentioned race/ethnicity, 63 performed analyses assessing for differences between exposure groups, 27 identified racial/ethnic differences, 22 adjusted outcomes for race/ethnicity in multivariable analyses, and 11 presented adjusted models stratified by race/ethnicity. None of the qualitative studies addressed the role that race, ethnicity, or racism may have had on the presented themes. CONCLUSIONS Few studies were designed to evaluate racial/ethnic inequities among maternal-infant dyads affected by OUD. Data on race/ethnicity have been poorly reported in this literature. To achieve health equity across perinatal OUD, researchers should prioritize the inclusion of marginalized groups to better address the role that structural racism plays.

OBJECTIVE The current literature has primarily focused on the 2-year outcomes of operative adult spinal deformity (ASD) treatment. Longer term durability is important given the invasiveness, complications, and costs of these procedures. The aim of this study was to assess minimum 3-year outcomes and complications of ASD surgery. METHODS Operatively treated ASD patients were assessed at baseline, follow-up, and through mailings. Patient-reported outcome measures (PROMs) included scores on the Oswestry Disability Index (ODI), Scoliosis Research Society–22r (SRS-22r) questionnaire, mental component summary (MCS) and physical component summary (PCS) of the SF-36, and numeric rating scale (NRS) for back and leg pain. Complications were classified as perioperative (≤ 90 days), delayed (90 days to 2 years), and long term (≥ 2 years). Analyses focused on patients with minimum 3-year follow-up. RESULTS Of 569 patients, 427 (75%) with minimum 3-year follow-up (mean ± SD [range] 4.1 ± 1.1 [3.0–9.6] years) had a mean age of 60.8 years and 75% were women. Operative treatment included a posterior approach for 426 patients (99%), with a mean ± SD 12 ± 4 fusion levels. Anterior lumbar interbody fusion was performed in 35 (8%) patients, and 89 (21%) underwent 3-column osteotomy. All PROMs improved significantly from baseline to last follow-up, including scores on ODI (45.4 to 30.5), PCS (31.0 to 38.5), MCS (45.3 to 50.6), SRS-22r total (2.7 to 3.6), SRS-22r activity (2.8 to 3.5), SRS-22r pain (2.3 to 3.4), SRS-22r appearance (2.4 to 3.5), SRS-22r mental (3.4 to 3.7), SRS-22r satisfaction (2.7 to 4.1), NRS for back pain (7.1 to 3.8), and NRS for leg pain (4.8 to 3.0) (all p < 0.001). Degradations in some outcome measures were observed between the 2-year and last follow-up evaluations, but the magnitudes of these degradations were modest and arguably not clinically significant. Overall, 277 (65%) patients had at least 1 complication, including 185 (43%) perioperative, 118 (27%) delayed, and 56 (13%) long term. Notably, the 142 patients who did not achieve 3-year follow-up were similar to the study patients in terms of demographic characteristics, deformities, and baseline PROMs and had similar rates and types of complications. CONCLUSIONS This prospective multicenter analysis demonstrated that operative ASD treatment provided significant improvement of health-related quality of life at minimum 3-year follow-up (mean 4.1 years), suggesting that the benefits of surgery for ASD remain durable at longer follow-up. These findings should prove useful for counseling, cost-effectiveness assessments, and efforts to improve the safety of care.

To examine insulin pump and continuous glucose monitoring (CGM) use with pregnancy-related outcomes in women with type 1 diabetes.We abstracted medical records of 646 pregnancies in 478 women with type 1 diabetes, with information on insulin pump versus multiple daily injection (MDI) use and CGM use. We analyzed the associations of pump vs. MDI use, CGM use vs. non-use and pregnancy-related outcomes using mixed effect models.Pump use was associated with lower HbA1c levels in the first [β (95% CI) = -0.33 (-0.51, -0.15) %] and second trimester [β (95% CI) = -0.13 (-0.24, -0.02) %], increased birth weight [β (95% CI) = 0.14 (0.02, 0.26) kg], birth weight percentile [β (95% CI) = 4.87 (0.49, 9.26) %], higher odds of large for gestational age [OR (95% CI) = 1.65 (1.06, 2.58)] and macrosomia [OR (95% CI) = 1.81 (1.03, 3.18)]. CGM use was associated with lower first [β (95% CI) = -0.38 (-0.64, -0.13) %] and third trimester [β (95% CI) = -0.17 (-0.33, -0.00) %] HbA1c levels.Women with type 1 diabetes who used pump or CGM had better glycemic control during pregnancy; however, pump use was associated with higher birth weight measures.

Retrospective cohort study.The aim of this study was to investigate the evolution of proximal junctional kyphosis (PJK) rate over 10-year enrollment period within a prospective database.PJK is a common complication following adult spinal deformity (ASD) surgery and has been intensively studied over the last decade.Patients with instrumentation extended to the pelvis and minimum 2-year follow-up were included. To investigate evolution of PJK/proximal junctional failure (PJF) rate, a moving average of 321 patients was calculated across the enrollment period. Logistic regression was used to investigate the association between the date of surgery (DOS) and PJK and/or PJF. Comparison of PJK/PJF rates, demographics, and surgical strategies was performed between the first and second half of the cohort.A total of 641 patients met inclusion criteria (age: 64±10 years, 78.2% female, body mass index: 28.3±5.7). The overall rate of radiographic PJK at 2 years was 47.9%; 12.9% of the patients developed PJF, with 31.3% being revised within 2-year follow-up. Stratification by DOS produced two halves. Between these two periods, rate of PJK and PJF demonstrated nonsignificant decrease (50.3%-45.5%, P =0.22) and (15.0%-10.9%, P =0.12), respectively. Linear interpolation suggested a decrease of 1.2% PJK per year and 1.0% for PJF. Patients enrolled later in the study were older and more likely to be classified as pure sagittal deformity ( P0.001). There was a significant reduction in the use of three-column osteotomies ( P0.001), an increase in anterior longitudinal ligament release ( P0.001), and an increase in the use of PJK prophylaxis (31.3% vs 55.1%). Logistical regression demonstrated no significant association between DOS and radiographic PJK ( P =0.19) or PJF ( P =0.39).Despite extensive research examining risk factors for PJK/PJF and increasing utilization of intraoperative PJK prophylaxis techniques, the rate of radiographic PJK and/or PJF did not significantly decrease across the 10-year enrollment period of this ASD database.

Retrospective study of a multicenter Adult Spinal Deformity (ASD) Database.To investigate the change in Pelvic tilt (PT) imparted by regional changes in lumbar lordosis at 2-year minimum follow up.The distribution of lumbar lordosis between L1-4 and L4-S1 is known to vary based on pelvic incidence (PI). However, the extent to which regional changes effect PT is not clearly elucidated. This information can be useful for ASD surgical planning.Operative patients from a multicenter ASD database were included with Lowest Instrumented Vertebrae (LIV) S1/Ilium,5 levels of fusion, Proximal Junction Kyphosis (PJK) angle 20, and5 degrees of change in lumbar lordosis from L4-S1 and L1-4. Radiographic analysis was performed evaluating Thoracic Kyphosis (TK), T10-L2 kyphosis (TL), L1-S1 lordosis (LL), L4-S1 lordosis, L1-4 lordosis, sagittal vertical axis (SVA) and PI-LL from preoperative to postoperative, and change at 2-years follow-up. Stepwise regression analysis was performed in order to determine the relationship between PT and the above radiographic parameters. Health-related quality of life (HRQOL) outcomes were also compared between preoperative and postoperative timepoints at 2 years.103 patients met inclusion for the study. There was improvement in all the radiographic parameters and HRQOLs at 2 years follow-up (p 0.01). Stepwise regression model showed an inverse relationship between PT and LL change (r = 0.71, p 0.01). Regionally, an increase in 10 degrees from L4-S1 correlated with a 2.4 degree decrease in PT (p 0.01), while an increase in 10 degrees from L1-4 resulted in a 1.6 degree decrease in PT (p 0.01).In the surgical planning for ASD, our data demonstrated significant correlational difference between corrections in the upper (L1-4) and lower (L4-S1) lumbar spine and PT changes. These calculations can be useful in planning sagittal plane corrections for ASD.

OBJECTIVE Hyperextension of C0–2 is a debilitating compensatory mechanism used to maintain horizontal gaze, analogous to high pelvic tilt in the lumbopelvic complex to maintain an upright posture. This study aims to investigate the impact of cervical deformity (CD) correction on this hyperextension. The authors hypothesize that correction of cervical sagittal malalignment allows for relaxation of C0–2 hyperextension and improved clinical outcomes. METHODS A retrospective review was conducted of a multicenter database of patients with CD undergoing spinal realignment and fusion caudal to C2 and cephalad to the pelvis. Range of motion (ROM) and reserve of extension (ROE) were calculated across C2–7 and C0–2. The association between C2–7 correction and change in C0–2 ROE was investigated while controlling for horizontal gaze, followed by stratification into ΔC2–7 percentiles. RESULTS Sixty-five patients were included (mean age 61.8 ± 9.6 years, 68% female). At baseline, patients had cervical kyphosis (C2–7, −11.7° ± 18.2°; T1 slope–cervical lordosis mismatch, 38.6° ± 18.6°), negative global alignment (sagittal vertical axis [SVA] −12.8 ± 71.2 mm), and hyperlordosis at C0–2 (mean 33.2° ± 11.8°). The mean ROM was 25.7° ± 17.7° and 21.3° ± 9.9° at C2–7 and C0–2, respectively, with an ROE of approximately 9° for each segment. Limited C0–2 ROM and ROE correlated with the Neck Disability Index (r = −0.371 and −0.394, p < 0.01). The mean number of levels fused was 7.0 ± 3.1 (24.6% anterior, 43.1% posterior), with 87.7% undergoing at least an osteotomy. At 1 year, mean C2–7 increased to 5.5° ± 13.4°, SVA became neutral (11.5 ± 54.8 mm), C0–2 hyperlordosis decreased to 27.8° ± 11.7°, and thoracic kyphosis (TK) increased to −49.4° ± 18.1° (all p < 0.001). Concurrently, mean C0–2 ROM increased to 27.6° ± 8.1° and C2–7 ROM decreased significantly to 9.0° ± 12.3° without a change in ROE. Controlling for horizontal gaze, change in C2–7 lordosis significantly correlated with increased TK (r = −0.617, p < 0.001), decreased C0–2 (r = −0.747, p < 0.001), and increased C0–2 ROE (r = 0.550, p = 0.002). CONCLUSIONS CD correction can significantly impact cephalad and caudal compensation in the upper cervical and thoracic spine. Restoration of cervical alignment resulted in increased C0–2 ROE and TK and was also associated with improved clinical outcome.

Experimental investigations were carried out in order to study the heat transfer performance of silver (Ag), multiwalled carbon nanotubes (MWCNT) and silver (Ag) + multiwalled carbon nanotubes (Ag + MWCNTs) dispersed in distilled water. Nanofluids were synthesized and characterized using different techniques. Experimental facility was fabricated to validate the heat transfer performance of nanofluids in the laminar flow. The nanofluids were tested at mass concentrations of 0.02%, 0.05%, 0.1%, 0.2% and 0.5% for all the three nanofluids. Experimental average heat transfer coefficient was evaluated as a function of Reynolds number. The highest heat transfer augmentation of 67.5% was observed for 0.5 mass% MWCNT/distilled water nanofluids followed by 59.8% for hybrid Ag-MWCNT/distilled water nanofluids, and the least enhancement of 52.1% was observed with Ag/distilled water nanofluids for Reynolds number 2200. The hybrid nanofluids showed better enhancement compared to silver nanofluids. The heat transfer showed an increase with Reynolds number and particle loading. New correlations were developed for the nanofluids for heat transfer enhancement.

Measurement is a core foundation of quality improvement (QI), and analysis of data for QI requires distinct approaches and tools as compared with other areas of healthcare. QI efforts can use structural, process, outcome, and balancing measures, and each measure should have a clear operational definition. Data for improvement should be analyzed dynamically over time, with a focus on understanding the variation present in the data. Distinguishing between common cause and special cause variation is necessary to evaluate and guide improvement efforts. Statistical process control tools such as run charts and control charts can be powerful tools to analyze data over time and help understand variation. This article continues a series of QI educational papers in the Journal of Perinatology, and offers a review of the use of data and measures to drive improvement.

The cutting fluid is significant in any metal cutting operation, for cooling the cutting tool and the surface of the workpiece, by lubricating the tool-workpiece interface and removing chips from the cutting zone. Recently, many researchers have been focusing on minimum quantity lubrication (MQL) among the numerous methods existing on the application of the coolant as it reduces the usage of coolant by spurting a mixture of compressed air and cutting fluid in an improved way instead of flood cooling. The MQL method has been demonstrated to be appropriate as it fulfills the necessities of ‘green’ machining. In the current study, firstly, various lubrication methods were introduced which are used in machining processes, and then, basic machining processes used in manufacturing industries such as grinding, milling, turning, and drilling have been discussed. The comprehensive review of various nanofluids (NFs) used as lubricants by different researchers for machining process is presented. Furthermore, some cases of utilizing NFs in machining operations have been reported briefly in a table. Based on the studies, it can be concluded that utilizing NFs as coolant and lubricant lead to lower tool temperature, tool wear, higher surface quality, and less environmental dangers. However, the high cost of nanoparticles, need for devices, clustering, and sediment are still challenges for the NF applications in metalworking operations. At last, the article identifies the opportunities for using NFs as lubricants in the future. It should be stated that this work offers a clear guideline for utilizing MQL and MQL-nanofluid approaches in machining processes. This guideline shows the physical, tribological, and heat transfer mechanisms associated with employing such cooling/lubrication approaches and their effects on different machining quality characteristics such as tool wear, surface integrity, and cutting forces.

Surgeons often rely on their intuition, experience and published data for surgical decision making and informed consent. Literature provides average values that do not allow for individualized assessments. Accurate validated machine learning (ML) risk calculators for adult spinal deformity (ASD) patients, based on 10 year multicentric prospective data, are currently available. The objective of this study is to assess surgeon ASD risk perception and compare it to validated risk calculator estimates.Nine ASD complete (demographics, HRQL, radiology, surgical plan) preoperative cases were distributed online to 100 surgeons from 22 countries. Surgeons were asked to determine the risk of major complications and reoperations at 72 h, 90 d and 2 years postop, using a 0-100% risk scale. The same preoperative parameters circulated to surgeons were used to obtain ML risk calculator estimates. Concordance between surgeons' responses was analyzed using intraclass correlation coefficients (ICC) (poor 0.5/excellent 0.85). Distance between surgeons' and risk calculator predictions was assessed using the mean index of agreement (MIA) (poor 0.5/excellent 0.85).Thirty-nine surgeons (74.4% with 10 years' experience), from 12 countries answered the survey. Surgeons' risk perception concordance was very low and heterogeneous. ICC ranged from 0.104 (reintervention risk at 72 h) to 0.316 (reintervention risk at 2 years). Distance between calculator and surgeon prediction was very large. MIA ranged from 0.122 to 0.416. Surgeons tended to overestimate the risk of major complications and reintervention in the first 72 h and underestimated the same risks at 2 years postop.This study shows that expert surgeon ASD risk perception is heterogeneous and highly discordant. Available validated ML ASD risk calculators can enable surgeons to provide more accurate and objective prognosis to adjust patient expectations, in real time, at the point of care.

Retrospective cohort study of a prospectively collected multi-center database of adult spinal deformity (ASD) patients.We hypothesized that patients undergoing ASD surgery with and without previous spinal cord stimulators (SCS)/ intrathecal medication pumps (ITP) would exhibit increased complication rates but comparable improvement in health-related quality of life.ASD patients sometimes seek pain management with SCS or ITP before spinal deformity correction. Few studies have examined outcomes in this patient population.Patients undergoing ASD surgery and eligible for 2-year follow-up were included. Preoperative radiographs were reviewed for the presence of SCS/ITP. Outcomes included complications, Oswestry Disability Index (ODI), Short Form-36 Mental Component Score, and SRS-22r. Propensity score matching was utilized.In total, of 1034 eligible ASD patients, a propensity score-matched cohort of 60 patients (30 with SCS/ITP, 30 controls) was developed. SCS/ITP were removed intraoperatively in most patients (56.7%, n = 17). The overall complication rate was 80.0% versus 76.7% for SCS/ITP versus control (P 0.2), with similarly nonsignificant differences for intraoperative and infection complications (all P 0.2). ODI was significantly higher among patients with SCS/ITP at baseline (59.2 vs. 47.6, P = 0.0057) and at 2-year follow-up (44.4 vs. 27.7, P = 0.0295). The magnitude of improvement, however, did not significantly differ (P = 0.45). Similar results were observed for SRS-22r pain domain. Satisfaction did not differ between groups at either baseline or follow-up (P 0.2). No significant difference was observed in the proportion of patients with SCS/ITP versus control reaching minimal clinically important difference in ODI (47.6% vs. 60.9%, P = 0.38). Narcotic usage was more common among patients with SCS/ITP at both baseline and follow-up (P 0.05).ASD patients undergoing surgery with SCS/ITP exhibited worse preoperative and postoperative ODI and SRS-22r pain domain; however, the mean improvement in outcome scores was not significantly different from patients without stimulators or pumps. No significant differences in complications were observed between patients with versus without SCS/ITP.Level of Evidence: 3.

OBJECTIVE Adult spinal deformity is a complex pathology that benefits greatly from surgical treatment. Despite continuous innovation, little is known regarding continuous changes in surgical techniques and the complications rate. The objective of the current study was to investigate the evolution of the patient profiles and surgical complications across a single prospective multicenter database. METHODS This study is a retrospective review of a prospective, multicenter database of surgically treated patients with adult spinal deformity (thoracic kyphosis > 60°, sagittal vertical axis > 5 cm, pelvic tilt > 25°, or Cobb angle > 20°) with a minimum 2-year follow-up. Patients were stratified into 3 equal groups by date of surgery. The three groups’ demographic data, preoperative data, surgical information, and complications were then compared. A moving average of 320 patients was used to visualize and investigate the evolution of the complication across the enrollment period. RESULTS A total of 928/1260 (73.7%) patients completed their 2-year follow-up, with an enrollment rate of 7.7 ± 4.1 patients per month. Across the enrollment period (2008–2018) patients became older (mean age increased from 56.7 to 64.3 years) and sicker (median Charlson Comorbidity Index rose from 1.46 to 2.08), with more pure sagittal deformity (type N). Changes in surgical treatment included an increased use of interbody fusion, more anterior column release, and a decrease in the 3-column osteotomy rate, shorter fusion, and more supplemental rods and bone morphogenetic protein use. There was a significant decrease in major complications associated with a reoperation (from 27.4% to 17.1%) driven by a decrease in radiographic failures (from 12.3% to 5.2%), despite a small increase in neurological complications. The overall complication rate has decreased over time, with the lowest rate of any complication (51.8%) during the period from August 2014 to March 2017. Major complications associated with reoperation decreased rapidly in the 2014–2015. Major complications not associated with reoperation had the lowest level (21.0%) between February 2014 and October 2016. CONCLUSIONS Despite an increase in complexity of cases, complication rates did not increase and the rate of complications leading to reoperation decreased. These improvements reflect the changes in practice (supplemental rod, proximal junctional kyphosis prophylaxis, bone morphogenetic protein use, anterior correction) to ensure maintenance of status or improved outcomes.