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Study design: Retrospective analysis. Objective: Analysis of a standardized, pre-surgical psychological evaluation program for complex spine surgery. Summary of background data: Adult spinal deformity (ASD) patients have a high rate of comorbid mental health conditions. Although there is a body of literature demonstrating the impact of psychological factors, including anxiety and depression, on spine surgery outcome, it is estimated that spine surgeons utilize a psychological assessment only about one third of the time prior to a patient’s spine surgery. At this time, there is not a widely reported pre-surgical psychological evaluation program for ASD patients. Methods: 129 consecutive complex spine surgery candidates receiving a pre-surgical psychological evaluation were analyzed between January 1st 2014 and December 31st 2018. Based on the available literature and professional experience in our facility, a color code for patients was developed from Green (low psychological or psychosocial co-morbidity) to Red (high psychological or psychosocial co-morbidity). Univariate analysis was used to evaluate between color grades and demographics, mental health disorders and outcomes. Results: 83% of complex spine patients had at least one psychological disorder or psychosocial barrier. Only 17% had a combination of realistic expectations for surgery, a good support plan, and were without a history of mental illness. The pre-surgical psychological color criteria were validated in showing higher rates of major depression, anxiety disorder, and bipolar disorder in moderate to severe color grades (p< .001) in addition to higher PHQ-9 and GAD-7 scores (p< .001). Patients having a more severe color grade had lower rates of a discharge home and were taking higher morphine equivalent dosages (MEDs) at their six-month follow-up, though both did not reach statistical significance (p= .07 and p= .08; respectively). Conclusion: A comprehensive pre-surgical psychological evaluation may be beneficial to risk stratify and counsel patients being evaluated for surgical reconstruction of adult spinal deformities. Level of evidence: 3

Purpose: We sought to determine the incidence, origin, and timeframe of delays to adult spinal deformity surgery so that institutions using preoperative multidisciplinary patient assessment teams might better anticipate and address these potential delays. Methods: Complex spine procedures for treatment of adult spinal deformity from 1/1/18 to 8/31/21 were identified. Procedures for infection, tumor, and urgent/emergent cases were excluded. Operations delayed due to COVID or those that were performed outside of our established perioperative care pathway were also excluded. The electronic health record was used to identify the etiology and timeline of all pre- and peri-operative delays. Results: Of 235 patients scheduled for complex spine surgery, 193 met criteria for inclusion. Of these patients, 35 patients experienced a surgical delay (18.1%) with a total of 41 delays recorded. Reasons for delay include medically unoptimized (25.6%), intraoperative complication (17.9%), patient directed delay (17.9%), patient illness/injury (15.4%), scheduling complication (10.3%), insurance delay/denial (5.1%), and unknown (2.6%). Twenty-four delays experienced by 22 individuals occurred within 7 days of their scheduled surgery date. Conclusion: At a single multidisciplinary center, most delays to adult spinal deformity surgery occur before a patient is admitted to the hospital, and for recommendations of additional medical workup/clearance. We suspect that the preoperative protocol might increase pre-admission delays for unoptimized patients, as the protocol is intended to ensure patients receive surgery only when they are medically ready. Further research is needed to determine the economic and system impact of delays related to a preoperative optimization protocol weighed against the reduction in adverse events these protocols can provide.

Sound decision‐making relies on accurate prediction for tangible outcomes ranging from military conflict to disease outbreaks. To improve crowdsourced forecasting accuracy, we developed SAGE, a hybrid forecasting systemthat combines human and machine generated forecasts. The system provides a platform where users can interact with machine models and thus anchor their judgments on an objective benchmark. The system also aggregates human and machine forecasts weighting both for propinquity and based on assessed skill while adjusting for overconfidence. We present results from the Hybrid Forecasting Competition (HFC)—larger than comparable forecasting tournaments—including 1085 users forecasting 398 real‐world forecasting problems over 8 months. Our main result is that the hybrid system generated more accurate forecasts compared to a human‐only baseline, which had no machine generated predictions. We found that skilled forecasters who had access to machine‐generated forecasts outperformed those who only viewed historical data. We also demonstrated the inclusion of machine‐generated forecasts in our aggregation algorithms improved performance, both in terms of accuracy and scalability. This suggests that hybrid forecasting systems, which potentially require fewer human resources, can be a viable approach for maintaining a competitive level of accuracy over a larger number of forecasting questions.

Purpose: To understand costs and provide an initial framework associated with conference implementation as it pertains to complication prevention. Methods: Team members' time spent on conference preparation, presentation, and follow-up tasks was recorded and averaged to determine the time required to prepare and present one patient. Using 2022 hourly wage rates based on our urban hospital setting, wage values were calculated for each personnel type and applied to their time spent. The total cost of the conference was annualized and calculated from the time spent in the three phases of the conference multiplied by the wage rate. Published data on complication rates and associated costs before and after conference implementation were used to calculate total cost reduction. Results: With 3 active spine surgeons and 108 patients per year, the total time investment was 104.04 min per patient, costing $21,791 annually. Total RN equivalent value per patient was 5.25 for all three phases. Using a historical model, this multidisciplinary approach for adult spinal deformity reduced complications by 51% at 30 days, resulting in cost savings of $418,518 per year. Thus, the model demonstrates that implementation of this approach resulted in a potential total savings of $396,726/year. Conclusion: Implementing a cost-saving tool for managing complex spinal disorders is a responsibility of the spine team, who should lead a multidisciplinary conference. The combination of TDABC and lean methodology can effectively demonstrate the variable costs associated with this multidisciplinary effort and models provide evidence of potential cost-savings when applied to a multidisciplinary adult spinal deformity conference. These findings should encourage clinicians and administrators to allocate resources to improve patient care by reducing complications and costs.

With growing government investment and a thriving consumer market, digital technologies are rapidly transforming our means of healthcare delivery. These innovations offer increased diagnostic accuracy, greater accessibility and reduced costs compared with conventional equivalents. Despite these benefits, implementing digital health poses challenges. Recent surveys of healthcare professionals (HCPs) have revealed marked inequities in digital literacy across the healthcare service, hampering the use of these new technologies in clinical practice. Furthermore, a lack of appropriate training in the associated ethical considerations risks HCPs running into difficulty when it comes to patient rights. In light of this, and with a clear need for dedicated digital health education, we argue that our focus should turn to the foundation setting of any healthcare profession: the undergraduate curriculum.

AbstractCOVID-19 outbreak has adversely affected the life of global population across the world. Efforts have been made to deal with the current grave situation from divergent areas viz. community, economic, science and medicine, digital technologies etc. In absence of potential remedial arrangements, best efforts could be directed towards minimizing the impact of COVID-19 on people’s health and economy. The present study focuses to provide a comprehensive model to reduce adverse impacts of COVID-19 disease to the minimum possible extent. A detailed review of scholarly works and web references is done on social, economic and technological interventions made to contain the impact of COVID-19. Relevant search key words were used on databases like Scopus, Ebsco, Google Scholar, etc. The second part of paper analyzes COVID-19 cases with respect to different economies of the world viz, upper income, middle income and lower income economies through Anova. Majority of the research works conducted on COVID-19 offer solutions from single perspectives. Present study suggested a conceptual model using multi-front approach considering social, economic and technological interventions. It also reveals mixed results about COVID-19 cases in different economies. There cannot be ‘one solution’ for controlling the pandemic and its aftermaths. Efforts are made to explore all possible ways ranging from display of socially accountable behaviors, economic reforms, medical research, and integration of AI and IoT with medical ecosystems. Surprisingly, COVID-19 has spread more in the high income economies of the world.

Study Design: Evaluation of new technology.Objectives: To evaluate the utility of a novel biomimetic spine model as a surgical planning and education resource in the treatment of cervical spine deformities (CSD).Methods: Three patients with CSD were identified and synthetic spine models were manufactured to match the anatomical and biomechanical properties of each patient. Each model underwent 3 phases of surgical correction: maximum correction with no osteotomies performed, with posterior column osteotomies (PCOs) only, and with PCOs and a 3-column osteotomy (3CO). Lateral fluoroscopic films were obtained after each phase of correction for measurement of cervical lordosis. Surgeons were surveyed to obtain subjective feedback on the perceived model utility.Results: Each model began with a kyphotic deformity that was mobile, rigid, or fixed. The mobile model achieved successive lordotic correction with each phase of correction. The rigid and fixed models achieved much less correction with no osteotomies and PCOs only, and the majority of correction with 3COs. Each model predicted with varying, but overall high, accuracy the amount of correction achieved in each patient. The surgeons felt the model had very high utility as a surgical education platform.Conclusions: The models appeared to accurately replicate the gross anatomy and biomechanical performance of the patients’ spines. This high fidelity to the individual patient’s anatomy, bone quality, and segmental mobility resulted in a custom model that provides an invaluable learning platform for surgical education. These results suggest the models may have utility in surgical planning, but further studies are needed.

Study Design: Structured Literature Review. Objectives: We sought to evaluate the peer-reviewed literature for potentially modifiable patient and surgical factors that could be incorporated into a Standard Work protocol to decrease complications in adult spinal deformity (ASD) surgery. Summary of Background Data: Lean Methodology uses Standard Work to improve efficiency and decrease waste and error. ASD is known to have a high surgical complication rate. Several patient and surgical potentially modifiable factors have been suggested to affect complications, including preoperative hemoglobin, bone density, body mass index (BMI), age-appropriate realignment, preoperative albumin/prealbumin, and smoking status. We sought to evaluate the literature for evidence supporting these factors to include in a Standard Work protocol to decrease complications. Methods: Each of these six factors was developed into an appropriate clinical question that included the patient population, surgical intervention, a comparison group, and outcomes measure (PICO question). A comprehensive literature search was then performed. The authors reviewed abstracts and analyzed data from included studies. From 456 initial citations with abstract, 173 articles underwent full-text review. The best available evidence for clinical questions regarding the influence of these factors was provided by 93 included studies. Results: We found fair evidence supporting a low preoperative hemoglobin level associated with increased transfusion rates and decreased BMD and increased BMI associated with increased complication rates. Fair evidence supported low albumin/prealbumin associated with increased complications. There was fair evidence associating smoking exposure to increased reoperations, but conflicting evidence associating it with increased complications. There was no evidence in the literature evaluating age-appropriate realignment and complications. Conclusion: Preoperative hemoglobin, bone density, body mass index, preoperative albumin/prealbumin, and smoking status all are potentially modifiable risk factors that are associated with increased complications in the adult spine surgery population. Developing a Standard Work Protocol for patient evaluation and optimization should include these factors. Level of Evidence: Level II.

Study Design: Structured literature review. Objectives: To review the current literature for potentially modifiable patient and surgical factors that could be incorporated into a Standard Work protocol to decrease complications in adult spinal deformity (ASD) surgery. Summary of Background Data: Application of lean methodology to health care involves standardization of work flow. Successful implementation of LEAN management can lead to dramatic reduction in variability and waste. Frailty, hemoglobin A1c (HbA1c) concentration, vitamin D level, mental health status, intraoperative fluid management (IFM), and tranexamic acid (TXA) administration may be modified to reduce complications after ASD surgery. Methods: Cochrane Central Register of Controlled Trials, MEDLINE/PubMed, Ovid, and Google Scholar databases were used to identify abstracts and citations for this review. Each topic was developed into an appropriate clinical question that included the patient population, surgical intervention, a comparison group, and outcomes measure (PICO question). From 373 initial citations with abstract, 134 articles underwent full-text review. The best available evidence for clinical questions regarding the influence of these factors was provided by 43 included studies. Results: We found fair evidence supporting an association between preoperative mental health disorders, frailty, vitamin D deficiency, and higher HbA1c levels and increased complications. Conversely, we found good evidence supporting an association between the use of intraoperative TXA and an optimized intraoperative fluid management and decreased complications. Conclusion: Gaps in the existing literature limit our ability to evaluate if all of the patient and surgical factors selected for this review are associated with increased or decreased complications and reoperations in ASD surgery. However, for both intraoperative TXA usage and optimized intraoperative fluid management that were supported by good evidence, developing Standard Work Protocols may optimize care. Level of Evidence: Level II.

The surgical correction of spinal deformities carries a high risk of perioperative morbidity. As the incidence of debilitating spinal deformities continues to increase, so too does our obligation to search for ways to enhance safety in our delivery of surgical care. Standardized work processes and other lean manufacturing methodologies have the potential to improve efficiency, safety, and hence value in our delivery of surgical care to patients with complex spine pathologies by reducing variability in our work processes. These principles can be applied to patient care from the initial preoperative assessment to long-term postoperative follow-up in the creation of comprehensive protocols that guide the management of these complex patients. Early evidence suggests that short-term outcomes can be improved by implementing packages of systems reform aimed at reducing variability in our work processes; however, contradicting evidence exists on the utility of several specific components of these systems-reform packages.

Structured Literature Review.

Structured literature review.

The surgical correction of spinal deformities carries a high risk of perioperative morbidity. As the incidence of debilitating spinal deformities continues to increase, so too does our obligation to search for ways to enhance safety in our delivery of surgical care. Standardized work processes and other lean manufacturing methodologies have the potential to improve efficiency, safety, and hence value in our delivery of surgical care to patients with complex spine pathologies by reducing variability in our work processes. These principles can be applied to patient care from the initial preoperative assessment to long-term postoperative follow-up in the creation of comprehensive protocols that guide the management of these complex patients. Early evidence suggests that short-term outcomes can be improved by implementing packages of systems reform aimed at reducing variability in our work processes; however, contradicting evidence exists on the utility of several specific components of these systems-reform packages.

Value in health care is defined as the quotient of outcomes to cost. Both pediatric and adult spinal deformity surgeries are among the most expensive procedures offered today. With high variability in both outcomes and costs in spine surgery today, surgeons will be expected to consider long-term cost effectiveness when comparing treatment options.

Introduction: Value in health care is defined as the quotient of outcomes to cost. Both pediatric and adult spinal deformity surgeries are among the most expensive procedures offered today. With high variability in both outcomes and costs in spine surgery today, surgeons will be expected to consider long-term cost effectiveness when comparing treatment options. Methods: We summarize various methods by which value can be increased in complex spine surgery, both through the improvement of outcomes and the reduction of cost. These methods center around standardization, team-based and collaborative approaches, rigorous outcomes tracking through dashboards and registries, and continuous process improvement. Results: This manuscript reviews the expert opinion of leading spine specialists on the improvement of safety, quality and improvement of value of pediatric and adult spinal surgery. Conclusion: Without surgeon leadership in this arena, suboptimal solutions may result from the isolated intervention of regulatory bodies or payer groups. The cooperative development of standardized, team-based approaches in complex spine surgery will lead to the high-quality, high-value care for patients.

Spinal deformity in the adult is a common medical disorder with a significant and measurable impact on health-related quality of life. The ability to measure and quantify patient self-reported health status with disease-specific and general health status measures, and to correlate health status with radiographic and clinical measures of spinal deformity, has enabled significant advances in the assessment of the impact of deformity on our population, and in the evaluation and management of spinal deformity using an evidence-based approach. There has been a significant paradigm shift in the evaluation and management of patients with adult deformity. The paradigm shift includes development of validated, disease-specific measures of health status, recognition of deformity in the sagittal plane as a primary determinant of health status, and information on results of operative and medical/interventional management strategies for adults with spinal deformity. Since its inception in 1966, the Scoliosis Research Society (SRS) has been an international catalyst for improving the research and care for patients of all ages with spinal deformity. The SRS Adult Spinal Deformity Committee serves the mission of developing and defining an evidence-based approach to the evaluation and management of adult spinal deformity. The purpose of this overview from the SRS Adult Deformity Committee is to provide current information on the epidemiology and impact of adult deformity, and to provide patients, physicians, and policy makers a guide to the evidence-based evaluation and management of patients with adult deformity.

Spinal deformity in the adult is a common medical disorder with a significant and measurable impact on health-related quality of life. The ability to measure and quantify patient self-reported health status with disease-specific and general health status measures, and to correlate health status with radiographic and clinical measures of spinal deformity, has enabled significant advances in the assessment of the impact of deformity on our population, and in the evaluation and management of spinal deformity using an evidence-based approach. There has been a significant paradigm shift in the evaluation and management of patients with adult deformity. The paradigm shift includes development of validated, disease-specific measures of health status, recognition of deformity in the sagittal plane as a primary determinant of health status, and information on results of operative and medical/interventional management strategies for adults with spinal deformity. Since its inception in 1966, the Scoliosis Research Society (SRS) has been an international catalyst for improving the research and care for patients of all ages with spinal deformity. The SRS Adult Spinal Deformity Committee serves the mission of developing and defining an evidence-based approach to the evaluation and management of adult spinal deformity. The purpose of this overview from the SRS Adult Deformity Committee is to provide current information on the epidemiology and impact of adult deformity, and to provide patients, physicians, and policy makers a guide to the evidence-based evaluation and management of patients with adult deformity.

Retrospective consecutive case series.

Study Design: Retrospective consecutive case series. Objectives: The objective of this study was to investigate the relationship between intraoperative and postoperative lumbar spine measurements after pedicle subtraction osteotomy (PSO). We analyzed the amount of lordosis lost between the prone intraoperative image and the final upright standing film. The outcome of this analysis should be used in preoperative planning for osteotomy procedures. Methods: Sixteen patients had pre-, intra- and postoperative measurements of lumbar lordosis. Pre- and postoperative measures of pelvic parameters were also determined. Comparisons were made between pre-, intra- and postoperative measures of pelvic parameters, with specific attention to lumbar lordosis correction and the loss of correction with transition to a standing position. Results: The average pelvic mismatch between preoperative lumbar lordosis and pelvic incidence was 37 degrees whereas the postoperative mismatch measured 3.2 degrees. All patients had a significant correction of their lumbar lordosis. The lumbar lordosis showed a highly significant loss of 12.5 degrees from the intraoperative prone position to the postoperative standing position, with the average lumbar lordosis intraoperatively (67 degrees) decreasing to a standing lumbar lordosis of 54 degrees (p <.000001). Conclusions: This analysis should aid in preoperative planning for sagittal global alignment correction and can reduce the chance of over- or under-correction in patients having a PSO procedure. Given the narrow postoperative target that is associated with better outcomes for patients, the loss of lumbar lordosis from prone to standing position may be a crucial variable in this planning process.

Study Design Systematic review.Clinical Questions (1) Has the proportion and number of randomized controlled trials (RCTs) as an indicator of quality of evidence regarding lumbar fusion increased over the past 10 years? (2) Is there a difference in the proportion of RCTs among the four primary fusion diagnoses (degenerative disk disease, spondylolisthesis, deformity, and adjacent segment disease) over the past 10 years? (3) Is there a difference in the type and quality of clinical outcomes measures reported among RCTs over time? (4) Is there a difference in the type and quality of adverse events measures reported among RCTs over time? (5) Are there changes in fusion surgical approach and techniques over time by diagnosis over the past 10 years?Methods Electronic databases and reference lists of key articles were searched from January 1, 2004, through December 31, 2013, to identify lumbar fusion RCTs. Fusion studies designed specifically to evaluate recombinant human bone morphogenetic protein-2 or other bone substitutes, revision surgery studies, nonrandomized comparison studies, case reports, case series, and cost-effectiveness studies were excluded.Results Forty-two RCTs between January 1, 2004, and December 31, 2013, met the inclusion criteria and form the basis for this report. There were 35 RCTs identified evaluating patients diagnosed with degenerative disk disease, 4 RCTs evaluating patients diagnosed with degenerative spondylolisthesis, and 3 RCTs evaluating patients with a combination of degenerative disk disease and degenerative spondylolisthesis. No RCTs were identified evaluating patients with deformity or adjacent segment disease.Conclusions This structured review demonstrates that there has been an increase in the available clinical database of RCTs using patient-reported outcomes evaluating the benefit of lumbar spinal fusion for the diagnoses of degenerative disk disease and degenerative spondylolisthesis. Gaps remain in the standardization of reportage of adverse events in such trials, as well as uniformity of surgical approaches used. Finally, continued efforts to develop higher-quality data for other surgical indications for lumbar fusion, most notably in the presence of adult spinal deformity and revision of prior surgical fusions, appear warranted.

Retrospective consecutive case review pre- and postintervention.

Study Design: Retrospective consecutive case review pre- and postintervention. Objectives: Characterize the effects of the intervention. Summary of Background Data: Complication rates in adult spinal deformity surgery are unacceptable. System approaches are necessary to increase patient safety. This group reported on the dual–attending surgeon approach, a live multidisciplinary preoperative screening conference, and the intraoperative protocol for the management of coagulopathy. The outcomes were demonstrated by complication rates before and after the institution of this protocol. Methods: Forty consecutive patients in Group A were managed without the 3-pronged approach. A total of 124 consecutive patients in Group B had a dual–attending surgeon approach, were presented and cleared by a live multidisciplinary preoperative conference, and were managed according to the intraoperative protocol. Results: Group A had an average age of 62 years (range, 39–84 years). Group B had an average age of 64 years (range, 18–84 years). Most patients in both groups had fusions from 9 to 15 levels. Complication rates in Group B were significantly lower (16% vs. 52%) (p <.001). Group B showed significantly lower return rates to the operating room during the perioperative 90-day period (0.8% vs. 12.5%) (p <.001). Group B also had lower rates of wound infection requiring debridement (1.6% vs. 7.5%), lower rates of deep vein thrombosis/ pulmonary embolism (3.2% vs. 10%), and lower rates of postoperative neurological complications (0.5% vs. 2.5%) (not significant). Group B had significantly lower rates of urinary tract infection requiring antibiotics (9.7% vs. 32.5%) (p <.001). Conclusions: These data suggests that a team approach consisting of a dual–attending surgeon approach in the operating room, a live preoperative screening conference, and an intraoperative protocol for managing coagulopathy will significantly reduce perioperative complication rates and enhance patient safety in patients undergoing complex spinal reconstructions for adult spinal deformity.

Twitter offers a powerful means to share information, suggest ways to help and highlight useful initiatives during the global COVID-19 pandemic. We describe one successful Twitter campaign focusing on the role of medical students (#MedStudentCovid), led by the volunteer organisation Becoming A Doctor with support from leaders at the General Medical Council, Health Education England, NHS England and the World Health Organization.

One approach to the modeling of bounded rationality in games is based on the dynamics of evolution and learning. An alternative static and equilibrium-based approach has been developed recently by Osborne and Rubinstein. This paper formalizes Osborne and Rubinstein's dynamic interpretation of their equilibrium concept, uses the criterion of dynamic stability as an equilibrium refinement, and shows that stable equilibria can involve the playing of strictly dominated actions while dominant strategy equilibria can be unstable. These effects cannot occur under standard evolutionary game dynamics. Sufficient conditions for the instability of equilibria are provided for symmetric and asymmetric games. Journal of Economic Literature Classification Number: C72.

We study the evolution of preference interdependence in aggregative games which are symmetric with respect to material payoffs but asymmetric with respect to player objective functions. We identify a class of aggregative games whose equilibria have the property that the players with interdependent preferences (who care not only about their own material payoffs but also about their payoffs relative to others) earn strictly higher material payoffs than do the material payoff maximizers. Implications of this finding for the theory of preference evolution are discussed. Journal of Economic LiteratureClassification Numbers: C72, D62.

This paper introduces a general model of a closed economy in which the dynamic disequilibrium interactions among labor, goods and asset markets are explored. The model contains many existing partial models as special cases, and gives rise to a four-dimensional dynamical system in general. Special cases of this system are studied analytically with respect to local stability in dimension three and global stability in dimension two. Here, the destabilizing role of fast adaptive expectations and price adjustment speeds (via the Mundell effect and the Rose effect) and the globally stabilizing role of increasing wage flexibility (via smooth factor substitution) are of particular importance.

This paper presents a higher-dimensional deterministic model of speculative asset price dynamics with heterogeneous agents. Fundamentalists speculate on departures of prices from fundamental values while chartists use extrapolative regression forecasts. Risk aversion of the latter is expressed as declining market participation when the dispersion of past prices increases. Over a wide range of parameter values this behaviour generates complex, aperiodic long-run dynamics. A special feature of the trajectories is a seemingly random sequence of “bull” and “bear” markets.

The replicator dynamics are generalized to allow for strategy-specific barriers to learning. The resulting dynamics satisfy neither payoff monotonicity nor payoff positivity, but do satisfy weak payoff positivity. It is shown that initial states from which trajectories converge to a rest point under the replicator dynamics may yield trajectories which approach a stable limit cycle under the generalized replicator dynamics. Furthermore, strategies which are strictly dominated by other pure strategies may survive indefinitely along such nonconvergent paths.Journal of Economic LiteratureClassification Numbers: C73.