Cracking the Hip: Does Protocol Matter? A Retrospective Cohort Study Investigating the Effect of Protocol Implementation.

INTRODUCTION: Approximately 300 000 hip fractures occur annually in the USA in patients >65 years old. Early intervention is key in reducing morbidity and mortality. Our institution implemented a collaborative hip fracture protocol, streamlining existing processes to reduce time to OR (TTO) and hospital length of stay (LOS). Our aim was to determine if this protocol improved these outcomes. STUDY DESIGN: We conducted a retrospective cohort study using our level-1 trauma center's trauma registry, comparing outcomes for patients >60 years old with isolated hip fractures pre-and post-hip protocol implementation in May 2018. Our primary outcomes were TTO and in-hospital mortality. Secondary outcomes included LOS and postoperative complications. Univariate analysis was done using chi-square and T-test. RESULTS: We identified 176 patients with isolated hip fractures: 69 post- and 107 pre-protocol. Comparing post- to pre-protocol, TTO decreased by 18hrs (39 vs 57h; P = .013) and patients had fewer postoperative complications (9 vs 23%; P = .016) despite post-protocol patients being more likely to have diabetes (42 vs 27%, P < .05), elevated BMI (22 vs 25; P < .001), and to be current smokers (9 vs 2%; P < .05). LOS and in-hospital mortality also decreased (11 vs 20d; P = .312, 4.3 vs 7.5%; P = .402). Post-protocol patients were more likely to go to the OR within 24hrs of presentation (39 vs 16%; P < .001) and to go straight from ED to OR (32 vs 4%; P < .001). CONCLUSION: TTO, LOS, and postoperative complications for isolated hip fracture patients were lower post-protocol. Though not all statistically significant, this trend indicates that the protocol was helpful in improving hip fracture outcomes but may require further improvement and institution-wide education.

Why Psychotropic Drugs Don't Cure Mental Illness-But Should They?

While pharmacological treatments for psychiatric disorders have offered great promise and have provided clinically meaningful symptom relief these treatments have had less effect on altering the course of these disorders. Research has provided many new insights about the effects of different psychotropic agents on the functions of various brain systems as investigators have embraced the "translational research model." However, this theoretical approach of deconstructing complex behaviors into smaller measurable behavioral units and targeting brain systems that are hypothesized to underlie these discrete behaviors has offered little of practical clinical relevance to significantly improve the treatment of psychiatric disorders in this century. Radical new treatments have not emerged, and available treatments continue to provide symptom relief without resolution of the underlying conditions. Recent publications on the subject have attempted to identify the barriers to progress and have pointed out some of the limitations of the translational approach. It is our position that, given the present limitations of our therapeutic arsenal, both researchers and clinicians would be well-advised to pay closer attention to human specific factors such as the role of language, the creation of personal narratives, and how factors such as these interface with underlying biological diatheses in mental illness. These interactions between pathophysiology and intrapersonal processes may be critical to both the in vivo expression of the underlying biological mechanisms of psychiatric disease states, and to the development of enhancements in therapeutic efficacy. Lastly, we discuss the implications of more coherently integrating neuroscientific research and clinical practice for more effectively addressing the challenges of understanding and treating mental illness.

Comparison of a Posterior versus Anterior Approach for Lumbar Interbody Fusion Surgery Based on Relative Value Units.

INTRODUCTION: The current value-driven healthcare system encourages physicians to continuously optimize the value of the services they provide. Relative value units (RVUs) serve as the basis of a reimbursement model linking the concept that as the effort and value of services provided to patient's increases, physician reimbursement should increase proportionately. Spine surgery is particularly affected by these factors as there are multiple ways to achieve similar outcomes, some of which require more time, effort, and risk. Specifically, as the trend of spinal interbody fusion has increased over the past decade, the optimal approach to use-posterior versus anterior lumbar interbody fusion (PLIF vs. ALIF)-has been a source of controversy. Due to potential discrepancies in effort, one factor to consider is the correlation between RVUs and the time needed to perform a procedure. Therefore, the purpose of this study was to compare: 1) mean RVUs; 2) mean operative time; and 3) mean RVUs per unit of time between PLIF and ALIF with the utilization of a national surgical database. We also performed an individual surgeon cost benefit analysis for performing PLIF versus ALIF. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was utilized to identify 6,834 patients who underwent PLIF (CPT code: 22630) and 6,985 patients who underwent ALIF (CPT code: 22558) between 2008 and 2015. The mean operative times (in minutes), mean RVUs, and RVUs per minute were calculated and compared using the Student's t-tests. In addition, the reimbursement amount (in dollars) per minute, case, day, and year for an individual surgeon performing PLIF versus ALIF were also calculated and compared. A p-value of less than 0.05 was used as the threshold for statistical significance. RESULTS: Compared to ALIF cases, PLIF cases had longer mean operative times (203 vs. 212 minutes, p<0.001). However, PLIF cases were assigned lower mean RVUs than ALIF cases (22.08 vs. 23.52, p<0.001). Furthermore, PLIF had a lower mean RVU/minutes than ALIF cases (0.126 vs. 0.154, p<0.001). The reimbursement amounts calculated for PLIF versus ALIF were: $4.52 versus $5.53 per minute, $958.66 versus $1,121.95 per case, and $2,875.98 versus $3,365.86 per day. The annual cost difference was $78,380.92. CONCLUSION: The data from this study indicates a potentially greater annual compensation of nearly $80,000 for performing ALIF as opposed to PLIF due to a higher "hourly rate" for ALIF as is noted by the significantly greater RVU per minute (0.154 vs. 0.126 RVU/minutes). These results can be used by spine surgeons to design more appropriate compensation effective practices while still providing quality care.

Septic arthritis of the hip and knee treated surgically in pediatric patients: Analysis of the Kids' Inpatient Database.

OBJECTIVE: This study evaluated incidence over time, any association between race and demographics, and hospital-related parameters in pediatric patients with septic hip or knee arthritis. METHODS: The Kids' Inpatient Database was used to identify all children with a diagnosis of septic hip or knee arthritis who underwent incision and drainage (1997-2012). RESULTS: Between 1997 and 2012, overall incidence of septic arthritis of the knee (0.20-0.33 per 100,000) and hip (0.12-0.18 per 100,000) increased. CONCLUSION: Incidence of pediatric septic joint arthritis, an emergent orthopaedic condition, has increased over time. Patient demographics may vary with respect to both age and race.

An assessment of an automated EEG biofeedback system for attention deficits in a substance use disorders residential treatment setting.

Attention deficits are prevalent among individuals with substance use disorders and may interfere with recovery. The present study evaluated the effectiveness of an automated electroencephalogram (EEG) biofeedback system in recovering illicit substance users who had attention deficits upon admission to a comprehensive residential treatment facility. All participants (n = 95) received group, family, and individual counseling. Participants were randomly assigned to 1 of 3 groups that either received 15 sessions of automated EEG biofeedback (AEB), 15 sessions of clinician guided EEG biofeedback (CEB), or 15 additional therapy sessions (AT). For the AEB and CEB groups, operant contingencies reinforced EEG frequencies in the 15-18 Hz (ß) and 12-15 Hz (sensorimotor rhythm, "SMR") ranges and reduce low frequencies in the 1-12 Hz (Δ, θ, and α) and 22-30 Hz (high ß) ranges. The Test of Variables of Attention (TOVA), a "Go-NoGo" task, was the outcome measure. Attention scores did not change on any TOVA measure in the AT group. Reaction time variability, omission errors, commission errors, and d' improved significantly (all p values < .01) in the AEB and CEB groups. AEB and CEB did not differ significantly from each other on any measure. The results demonstrate that automated neurofeedback can effectively improve attention in recovering illicit substance users in the context of a comprehensive residential substance abuse treatment facility.

Plasticity in brain processing and modulation of pain.

Brain processing of pain in humans is based on multiple ascending pathways and brain regions that are involved in several pain components, such as sensory, immediate affective, and secondary affective dimensions. These dimensions are processed both serially and in parallel. They include spinal ascending pathways that directly target limbic and brainstem structures involved in pain-related emotions as well as a pathway proceeding from the somatosensory cortices to limbic cortical areas. Superimposed on this neural organization is the capacity to process the dimensions of pain in multiple ways, as in patients who lack one cerebral hemisphere but can nevertheless locate and rate pain intensity and pain unpleasantness on both sides of the body. The dimensions of pain also can be psychologically modulated in multiple ways and these changes are accompanied by corresponding changes in relevant brain structures. Finally, understanding psychological modulation of pain and pain-related brain activity is optimized by a scientific framework that integrates principles of contemporary physics, neuroscience, and human experiential science.

Quantum physics in neuroscience and psychology: a neurophysical model of mind-brain interaction.

Neuropsychological research on the neural basis of behaviour generally posits that brain mechanisms will ultimately suffice to explain all psychologically described phenomena. This assumption stems from the idea that the brain is made up entirely of material particles and fields, and that all causal mechanisms relevant to neuroscience can therefore be formulated solely in terms of properties of these elements. Thus, terms having intrinsic mentalistic and/or experiential content (e.g. 'feeling', 'knowing' and 'effort') are not included as primary causal factors. This theoretical restriction is motivated primarily by ideas about the natural world that have been known to be fundamentally incorrect for more than three-quarters of a century. Contemporary basic physical theory differs profoundly from classic physics on the important matter of how the consciousness of human agents enters into the structure of empirical phenomena. The new principles contradict the older idea that local mechanical processes alone can account for the structure of all observed empirical data. Contemporary physical theory brings directly and irreducibly into the overall causal structure certain psychologically described choices made by human agents about how they will act. This key development in basic physical theory is applicable to neuroscience, and it provides neuroscientists and psychologists with an alternative conceptual framework for describing neural processes. Indeed, owing to certain structural features of ion channels critical to synaptic function, contemporary physical theory must in principle be used when analysing human brain dynamics. The new framework, unlike its classic-physics-based predecessor, is erected directly upon, and is compatible with, the prevailing principles of physics. It is able to represent more adequately than classic concepts the neuroplastic mechanisms relevant to the growing number of empirical studies of the capacity of directed attention and mental effort to systematically alter brain function.

Electroconvulsive Therapy and Brain Glucose Metabolism.

The local cerebral metabolic rate for glucose (LCMRGlc) was evaluated in four patients before undergoing a course of electroconvulsive therapy (ECT) and after its completion. There was no reduction in LCMRGlc when studied 1 day after the last course of ECT. There was, however, the suggestion that metablic rates may increase in the middle frontal gyrus after significant time has elapsed since the last course of ECT.