Thoracoscopic scoliosis surgery – a cheaper option? A cost analysis of 189 consecutive cases

INTRODUCTION: Increasing health care costs, limited resources and increased demand makes cost effective and cost-efficient delivery of Adolescent Idiopathic Scoliosis (AIS) management paramount. Rising implant costs in deformity correction surgery have prompted analysis of whether high implant densities are justified. The objective of this study was to analyse the costs of thoracoscopic scoliosis surgery, comparing initial learning curve costs with those of the established technique and to the costs involved in posterior instrumented fusion from the literature. METHODS: 189 consecutive cases from April 2000 to July 2011 were assessed with a minimum of 2 years follow-up. Information was gathered from a prospective database covering perioperative factors, clinical and radiological outcomes, complications and patient reported outcomes. The patients were divided into three groups to allow comparison; 1. A learning curve cohort, 2. An intermediate cohort and 3. A third cohort of patients, using our established technique. Hospital finance records and implant manufacturer figures were corrected to 2013 costs. A literature review of AIS management costs and implant density in similar curve types was performed. RESULTS: The mean pre-op Cobb angle was 53°(95%CI 0.4) and was corrected postop to mean 22.9°(CI 0.4). The overall complication rate was 20.6%, primarily in the first cohort, with a rate of 5.6% in the third cohort. The average total costs were $46,732, operating room costs of $10,301 (22.0%) and ICU costs of $4620 (9.8%). The mean number of screws placed was 7.1 (CI 0.04) with a single rod used for each case giving average implant costs of $14,004 (29.9%). Comparison of the three groups revealed higher implant costs as the technique evolved to that in use today, from $13,049 in Group 1 to $14577 in Group 3 (P<0.001). Conversely operating room costs reduced from $10,621 in Group 1 to $7573 (P<0.001) in Group 3. ICU stay was reduced from an average of 1.2 to 0 days. In-patient stay was significantly (P=0.006) lower in Groups 2 and 3 (5.4 days) than Group 1 (5.9 days) (i.e. a reduction in cost of approximately $6,140). CONCLUSIONS: The evolution of our thoracoscopic anterior scoliosis correction has resulted in an increase in the number of levels fused and reduction in complication rate. Implant costs have risen as a result, however, there has been a concurrent decrease in those costs generated by operating room use, ICU and in-patient stay with increasing experience. Literature review of equivalent curve types treated posteriorly shows similar perioperative factors but higher implant density, 69-83% compared to the 50% in this study. Thoracoscopic Scoliosis surgery presents a low density, reliable, efficient and effective option for selected curves. A cost analysis of Thoracoscopic Scoliosis Surgery using financial records and a prospectively collected database of all patients since 2000, demonstrating a clear cost advantage compared to equivalent posterior instrumentation and fusion.

Knowledge Based Urban Development

The changing and challenging conditions of the 21st century have been significantly impacting our economy, society and built and natural environments. Today generation of knowledge—mostly in the form of technology and innovation—is seen as a panacea for the adaptation to changes and management of challenges (Yigitcanlar, 2010a). Making space and place that concentrate on knowledge generation, thus, has become a priority for many nations (van Winden, 2010). Along with this movement, concepts like knowledge cities and knowledge precincts are coined as places where citizenship undertakes a deliberate and systematic initiative for founding its development on the identification and sustainable balance of its shared value system, and bases its ability to create wealth on its capacity to generate and leverage its knowledge capabilities (Carrillo, 2006; Yigitcanlar, 2008a). In recent years, the term knowledge precinct (Hu & Chang, 2005) in its most contemporary interpretation evolved into knowledge community precinct (KCP). KCP is a mixed-use post-modern urban setting—e.g., flexible, decontextualized, enclaved, fragmented—including a critical mass of knowledge enterprises and advanced networked infrastructures, developed with the aim of collecting the benefits of blurring the boundaries of living, shopping, recreation and working facilities of knowledge workers and their families. KCPs are the critical building blocks of knowledge cities, and thus, building successful KCPs significantly contributes to the formation of prosperous knowledge cities. In the literature this type of development—a place containing economic prosperity, environmental sustainability, just socio‐spatial order and good governance—is referred as knowledge-based urban development (KBUD). This chapter aims to provide a conceptual understanding on KBUD and its contribution to the building of KCPs that supports the formation of prosperous knowledge cities.

Generalized azimuthal shear deformations in compressible isotropic elastic materials

In this article we study the azimuthal shear deformations in a compressible Isotropic elastic material. This class of deformations involves an azimuthal displacement as a function of the radial and axial coordinates. The equilibrium equations are formulated in terms of the Cauchy-Green strain tensors, which form an overdetermined system of partial differential equations for which solutions do not exist in general. By means of a Legendre transformation, necessary and sufficient conditions for the material to support this deformation are obtained explicitly, in the sense that every solution to the azimuthal equilibrium equation will satisfy the remaining two equations. Additionally, we show how these conditions are sufficient to support all currently known deformations that locally reduce to simple shear. These conditions are then expressed both in terms of the invariants of the Cauchy-Green strain and stretch tensors. Several classes of strain energy functions for which this deformation can be supported are studied. For certain boundary conditions, exact solutions to the equilibrium equations are obtained. © 2005 Society for Industrial and Applied Mathematics.

Enhancing paramedics procedural skills using a cadaveric model

Background Paramedic education has evolved in recent times from vocational post-employment to tertiary pre-employment supplemented by clinical placement. Simulation is advocated as a means of transferring learned skills to clinical practice. Sole reliance of simulation learning using mannequin-based models may not be sufficient to prepare students for variance in human anatomy. In 2012, we trialled the use of fresh frozen human cadavers to supplement undergraduate paramedic procedural skill training. The purpose of this study is to evaluate whether cadaveric training is an effective adjunct to mannequin simulation and clinical placement. Methods A multi-method approach was adopted. The first step involved a Delphi methodology to formulate and validate the evaluation instrument. The instrument comprised of knowledge-based MCQs, Likert for self-evaluation of procedural skills and behaviours, and open answer. The second step involved a pre-post evaluation of the 2013 cadaveric training. Results One hundred and fourteen students attended the workshop and 96 evaluations were included in the analysis, representing a return rate of 84%. There was statistically significant improved anatomical knowledge after the workshop. Students' self-rated confidence in performing procedural skills on real patients improved significantly after the workshop: inserting laryngeal mask (MD 0.667), oropharyngeal (MD 0.198) and nasopharyngeal (MD 0.600) airways, performing Bag-Valve-Mask (MD 0.379), double (MD 0.344) and triple (MD 0.326,) airway manoeuvre, doing 12-lead electrocardiography (MD 0.729), using McGrath(R) laryngoscope (MD 0.726), using McGrath(R) forceps to remove foreign body (MD 0.632), attempting thoracocentesis (MD 1.240), and putting on a traction splint (MD 0.865). The students commented that the workshop provided context to their theoretical knowledge and that they gained an appreciation of the differences in normal tissue variation. Following engagement in/ completion of the workshop, students were more aware of their own clinical and non-clinical competencies. Conclusions The paramedic profession has evolved beyond patient transport with minimal intervention to providing comprehensive both emergency and non-emergency medical care. With limited availability of clinical placements for undergraduate paramedic training, there is an increasing demand on universities to provide suitable alternatives. Our findings suggested that cadaveric training using fresh frozen cadavers provides an effective adjunct to simulated learning and clinical placements.

A matrix converter based Inductive Power Transfer system

Typical Inductive Power Transfer (IPT) systems employ two power conversion stages to generate a high frequency current from low frequency utility supply. This paper proposes a matrix converter based IPT system that facilitates the generation of high frequency current through a single power conversion stage. The proposed matrix converter topology transforms a 3-phase low frequency voltage system to a high frequency single phase voltage which in turn powers a series compensated IPT system. A comprehensive mathematical model is developed to investigate the behavior of the proposed IPT topology. Theoretical results are presented in comparison to simulations, which are performed in Matlab/ Simulink, to demonstrate the applicability of the proposed concept and the validity of the developed model.

Solar evaporator-collectors : analyses and applications

Taking into consideration of growing energy needs and concern for environmental degradation, clean and inexhaustible energy source, such as solar energy, is receiving greater attention for various applications. The use of solar energy system reduces pollution, waste and has little or no harmful effects on the environment. It is appreciated that this source of energy can be complementary rather than being competitive to conventional energy sources. In order to collect and harness energy from the sun, a solar collector is essential. A solar collector is basically a heat exchanger that transforms solar radiant energy into heat or thermal energy. Improvement of performance is essential for commercial acceptance of their use in such applications. Many studies have been undertaken on the enhancement of thermal performance of solar collectors, using diverse materials of various shapes, dimensions and layouts. In the literature, various collector designs have been proposed and tested with the objective of meeting these requirements [1-8]. Omer et al. [1] found the efficiency of a solar collector of about 70% in a solar assisted heat pump system. Traditional solar collectors are single phase collectors, in which the working fluid is either air or water. Different modifications are suggested and applied to improve the heat transfer between the absorber and working fluid in a collector. These modifications include the use of absorber with fins attached [2,3], corrugated absorber [4,5], matrix type absorber [6], V-groove solar air collector [7]. Karim et al. [8] approached a review of design and construction of three types (flat, vee-grooved, and finned) of air collectors. Two-phase collectors, on the other hand, have significant potential for continuous operation round the clock, when used in conjunction with a compressor, as found in a solar assisted heat-pump cycle.

Connecting theory, practice and place in today’s landscape : an education initiative

Since the establishment of Australia’s earliest formal studies in landscape architecture, landscape planning has been a traditional focus within post-graduate studies at QUT. Study in this area has evolved from an earlier emphasis on applied physical geography through to traditional techniques and processes in visual assessment and management. The emphasis on these techniques has shifted again to a more complex exploration of natural, economic, social and cultural landscapes. Recently, the School has explored more innovative and complex dimensions of human and natural landscapes. This has involved a focus on particular regions under pressure from local social and economic change. These have included the under-threat ‘picturesque’ landscapes of the Blackall Range and the Tweed Valley. Attempts to bridge the institution and the landscape have unearthed, through a studio focus, strong connections with notions of sustainable villages, roadside interpretation, way finding, local economic initiatives, special area creation, cultural heritage brokering and ecological enhancements. These initiatives have spanned both local practice interests and academic pursuits. Central to this exploration is the concept of problem solving through the investigation of the concept of ‘multiple scales’. An open, yet intensive program is being developed with a team of ‘futurist’ practitioners offering a range of experiences and perspectives to students. The program is being increasingly linked to design studios so that landscape planning and landscape design form a fabric of inquiry that works towards reclaiming complex landscapes.

A business perspective of legacy systems

Abstract Legacy information systems evolved incrementally in response to changes in business strategy and information technology. Organizations are now being forced to change much more radically and quickly than previously and this change places new demands on information systems. Legacy information systems are usually considered from a technical perspective, addressing issues such as age, complexity, maintainability, design and technology. We wish to demonstrate that the business dimension to legacy information systems, represented by the organisation structure, business processes and procedures that are bound up in the design and operation of the existing IT systems, is also significant. This paper identifies the important role of legacy information systems in the formation of new strategies. We show that the move away from a stable to an unstable business environment accelerates the rate of change. Furthermore, the gap between what the legacy information systems can deliver and the strategic vision of the organization widens when the legacy information systems are unable to adapt to meet the new requirements. An analysis of fifteen case studies provides evidence that legacy information systems include business and technical dimensions and that the systems can present problems when there is a misalignment between the strategic vision of the business, the IT legacy and the old business model embodied in the legacy.

Grading : A Workbook of Manual Land Grading Techniques [Revised Edition]

Grading is basic to the work of Landscape Architects concerned with design on the land. Gradients conducive to easy use, rainwater drained away, and land slope contributing to functional and aesthetic use are all essential to the amenity and pleasure of external environments. This workbook has been prepared specifically to support the program of landscape construction for students in Landscape Architecture. It is concerned primarily with the technical design of grading rather than with its aesthetic design. It must be stressed that the two aspects are rarely separate; what is designed should be technically correct and aesthetically pleasing - it needs to look good as well as to function effectively. This revised edition contains amended and new content which has evolved out of student classes and discussion with colleagues. I am pleased to have on record that every delivery of this workbook material has resulted in my own better understanding of grading and the techniques for its calculation and communication.

Crowdsourcing in developing countries : a possible model to co-create with the poor

The interest in poverty and the moral sense of'helping the poor' are a constant topic in Western culture (Mayo 2009).ln recent years, multinational corporations (MNCs) have evolved in their understanding of how social issues, such as poverty alleviation, relate to their fundamental purposes. From a business strategy point of view, 'socially responsible' initiatives are generally born with lhe dual purpose of attaining social visibility (i.e. marketing) and increasing economic returns. Besides addressing social challenges as part of their corporate social responsibility strategies, MNCs have also begun 'selling to the poor' in emerging markets (Prahalad 2004). A few forward -looking companies consider tltis base of the pyramid (BOP) market also as a source of innovation and have started to co-create with consumers (Simanis and Hart 2008).

Building a community of learners within the STEM higher education classroom

Building rich and authentic learning experiences in the STEM classroom, is a challenge for many educators within Higher Education. While many Higher Education Institutions have embraced the need to transform current teaching and learning practices and include a range of online tools, this has often been met with some resistance and approaches that do not always recognise the academic who are a critical component to the success of the transformational process. Over the last decade the Internet has evolved from being a tool used by a few dedicated educators to one that is being used by the majority of educators. However, what is important is how this great resource is used in teaching and learning to allow students to build knowledge. The ability for students to construct knowledge and engage in higher order thinking skills is at the heart of educational practices, and building a community of learners has the potential to support these practices, especially within STEM education. This paper explores the relationship between students and an academic teaching in a technology rich STEM learning environment and their adoption of social community and shared tools. In particular the paper reports on the critical components that make a successful community of learners and the educational tools and approaches that were successfully used to enhance the student learning experience in a STEM classroom.

Australian consumer attitudes and decision making on renewable energy technology and its impact on the transformation of the energy sector

This paper critically examines research on consumer attitudes and behavior towards solar photovoltaic (PV) and renewable energy technology in Australia. The uptake of renewable energy technology by residential consumers in Australia in the past decade has transformed the electricity supply and demand paradigm. Thus, this paper reviews Australian research on consumer behavior, understanding and choices in order to identify gaps in knowledge. As the role of the consumer transforms there is a critical need to understand the ways consumers may respond to future energy policies to mitigate unforeseen negative social and economic consequence of programs designed to achieve positive environmental outcomes.

Regulatory interplay between pap operons in uropathogenic Escherichia coli

Pathogenic bacteria have a large repertoire of surface organelles involved in adherence, motility and protein export, but how individual bacteria co-ordinate surface organelle expression to prevent interference and excessive immune stimulation is unclear. Phase variation is a mechanism by which expression of surface factors is limited to a fraction of the bacterial population; however, the presence of multiple homologous surface structures controlled by related mechanisms and regulators antagonizes the independent expression achieved by phase variation. To investigate whether other mechanisms have evolved to sort out the bacterial cell surface, we examined regulatory cross-talk between multiple phase-variable pyelonephritis-associated pili (pap) operons in Escherichia coli isolates associated with urinary tract infections. Allelic variation identified in the regulatory regions and regulators acts synergistically to limit coexpression of homologous fimbrial operons. In particular, there is evidence that papI is under positive selection and PapI variants displayed differences in their capacity to activate related pap operons. Alleles of the high-affinity binding site for PapB were shown to contain a variable number of (T/A)3 repeats occurring every 9 bp that altered the sensitivity of pap operon activation. Taken together with other examples of surface organelle cross-talk, we illustrate how this regulation could promote sequential expression.

Evolution to a chronic disease niche correlates with increased sensitivity to tryptophan availability for the obligate intracellular bacterium Chlamydia pneumoniae

The chlamydiae are obligate intracellular parasites that have evolved specific interactions with their various hosts and host cell types to ensure their successful survival and consequential pathogenesis. The species Chlamydia pneumoniae is ubiquitous, with serological studies showing that most humans are infected at some stage in their lifetime. While most human infections are asymptomatic, C. pneumoniae can cause more-severe respiratory disease and pneumonia and has been linked to chronic diseases such as asthma, atherosclerosis, and even Alzheimer's disease. The widely dispersed animal-adapted C. pneumoniae strains cause an equally wide range of diseases in their hosts. It is emerging that the ability of C. pneumoniae to survive inside its target cells, including evasion of the host's immune attack mechanisms, is linked to the acquisition of key metabolites. Tryptophan and arginine are key checkpoint compounds in this host-parasite battle. Interestingly, the animal strains of C. pneumoniae have a slightly larger genome, enabling them to cope better with metabolite restrictions. It therefore appears that as the evolutionarily more ancient animal strains have evolved to infect humans, they have selectively become more "susceptible" to the levels of key metabolites, such as tryptophan. While this might initially appear to be a weakness, it allows these human C. pneumoniae strains to exquisitely sense host immune attack and respond by rapidly reverting to a persistent phase. During persistence, they reduce their metabolic levels, halting progression of their developmental cycle, waiting until the hostile external conditions have passed before they reemerge.

Oestrogen and progestin responses in human endometrium

Our understanding of the mechanisms of the actions of oestrogens and progestins have evolved from the simple concept of nuclear receptor-mediated regulation of transcription to a highly sophisticated, finely tuned interplay between various coregulators, other signaling cascades and transcription factors. The net result of these complex regulatory mechanisms is a steroid-, cell-, or tissue-specific action of oestrogens and progestins. their antagonists or selective modulators of their receptors. In this review, we have attempted to shed some light on the regulation of the actions of oestrogens and progestins on the human endometrium. (C) 2003 Elsevier Science Ltd. All rights reserved.