Articles: cations.
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The optimal site for placement of tissue oxygen probes following traumatic brain injury (TBI) remains unresolved. We studied brain tissue oxygen tension (PbtO2) at the sites of contusion, proximal and distal to contusion, and in the contralateral hemisphere to determine the effect of probe location on PbtO2 and to assess the effects of physiological interventions on PbtO2 at these different sites. ⋯ PbtO2 measurements are strongly influenced by the distance from the site of focal injury. Physiological alterations, including hyperoxia, hyperventilation, and hypoventilation substantially affect PbtO2 values distal to the site of injury, but have little effect in and around the site of contusion.
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Recent efforts to improve health care quality have focused on variations in outcomes such as 30-day readmissions (30d-R). Pay-for-performance programs hold providers accountable to reduce these variations, with the assumption that variations are due to discretionary practices of providers and can be influenced by changes in reimbursement. We examined variations in length of stay (LOS) and 30d-R among the surgeons for elective lumbar spine surgery for degenerative conditions to determine if these outcomes are a valid target for pay for performance programs. ⋯ We found significant variations in LOS by surgeon after adjusting for patient characteristics and type of surgery. This suggests that surgeon practice varies and impacts length of stay. Yet, we found no variation in 30d-R by surgeon, implying that surgeon practice variation does not affect 30d-R. Thus, pay-for-performance programs aimed at providers are unlikely to improve 30d-R.
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On reviewing the database of patients with craniovertebral junction anomalies, the authors identified 70 patients with a bifid posterior arch of atlas. ⋯ Understanding of the pathogenesis and mechanical alterations in cases with a bifid arch of atlas can assist in evaluating the clinical implications and in conduct of surgery.
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Failed back surgery syndrome (FBSS) is a type of neuropathic pain where extremity symptoms persist despite structurally corrective spinal surgery. This implies more substantial nerve damage rather than simply dysfunction whereby correcting the inciting structural derangement does not provide for clinical resolution. What remains unclear is how to predict which patients are likely to derive benefit from surgical intervention, and whether specific pain characteristics are associated with different likelihoods of good outcome. ⋯ While FBSS was more common among younger and female patients, this occurred with low overall frequency. Higher neuropathic pain screening scores correlated strongly with the likelihood and severity of significant postoperative leg pain. Further work is required to develop more accurate prognostication tools for patients undergoing structural spinal surgery for lumbar radiculopathy.
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Value-base purchasing and pay-for-performance models are driving the development of bundle payment systems for reimbursement. To build a sustainable bundling system, it is important to identify the contributions of each component of index surgery total cost and determine the domain where targeted savings can occur. We determined the percent contribution of health care resource utilization, hospital fee, surgeon's fee, and readmission to total cost of index surgery following elective spine surgery. ⋯ Hospital fee had the largest contribution (75%) to the total cost of index surgery, followed by readmissions (21%). Surgeon's fee and health care resource utilization had much smaller contributions to total cost. True cost savings can occur through engagement and partnering between hospital and surgeon to decrease hospital fees. Reducing readmission episodes and understanding and reducing modifiable drivers of hospital fees have the potential to decrease total direct cost for elective spine surgery.