Electromagnetic Force-Driven Needle-Free in Ovo Injection Device.

Needle-free injections are mainly used for administering human or mammalian vaccines or drugs. However, poultry vaccines, in ovo injections to embryos, subcutaneous injections to chickens, and intramuscular injections are administered using needle injections. This article presents a new needle-free in ovo injection device method that uses push-pull solenoids to eject liquid jets, mainly for embryonic eggs of chickens. Furthermore, our study investigated the suitable jet pressures for using this method and the post-injection hatching rates in 18-day-old embryonic eggs. Using this method, we could deliver the liquid to the allantoic and amniotic cavities or the muscle tissue through the egg membrane of the air chamber using a jet pressure of ~6-7 MPa or ~8 MPa. After injecting 0.25 mL of 0.9% saline into 18-day-old Lohmann breed layer embryonic eggs and specific pathogen-free (SPF) embryonic eggs at a jet pressure of ~7 MPa, we observed hatching rates of 98.3% and 85.7%, respectively. This study's electromagnetic needle-free in ovo injection device can apply vaccine or nutrient solution injection for embryo eggs and serve as a reference for future studies on needle-free in ovo injection automation systems, jet pressure control, and injection pretreatment processes.

Complaints Matter: Seriousness of Elder Mistreatment Citations in Nursing Homes Nationwide.

Mistreatment of nursing home residents is prevalent and leads to harmful consequences. The Centers for Medicare & Medicaid Services's (CMS) mission to protect residents' right to be free from mistreatment is implemented partially through state survey agencies' (SSAs) issuance of deficiency citations. The goal of this study was to compare SSA standard surveys and SSA complaint investigations with regard to the seriousness (scope and severity) of the mistreatment citations issued. A cumulative link mixed model was built to estimate the differences between standard surveys and complaint investigations in the seriousness of four core and two secondary mistreatment citations nationwide from 2014 to 2017. In all of the six mistreatment deficiency citations, complaint investigations were more likely to be determined as more serious compared with standard surveys. The findings reinforce the importance of strengthening nursing homes' and CMS/SSA response to consumers' concerns and grievances before they escalate into more harmful mistreatment.

Duck Eggshell Crack Detection by Nondestructive Sonic Measurement and Analysis.

Duck eggs are a good source of essential nutrients for the human body. However, transportation, processing, and handling can easily cause cracks in the eggshells. These cracks can lead to microbial contamination, reducing the shelf life and compromising food safety. In this study, a method for the nondestructive testing of cracks in duck eggshells was developed. First, the acoustic emission signals of intact and cracked eggshells were measured, and the most significant frequency features were selected to establish a calibration curve for cracked eggshells. Logistic regression using the frequency features was then adopted to predict intact and cracked eggshells. Then, we establish a set of optimal regression models and used independent samples for verification. The overall accuracy rates of the calibration and prediction models using five frequencies of bandwidth (1500, 5000, 6000, 8500, and 10,000 Hz) were 89.7% and 87.6%, respectively. Sound measurement enables a simple and quantitative method for duck egg crack detection and classification. This nondestructive and cost-effective method can be used for duck egg quality screening and can be integrated into duck egg processing machinery.

Real-Time Gauging of the Gelling Maturity of Duck Eggs Pickled in Strong Alkaline Solutions.

Although many ultraviolet-visible-near-infrared transmission spectroscopy techniques have been applied to chicken egg studies, such techniques are not suitable for duck eggs because duck eggshells are much thicker than chicken eggshells. In this study, a high-transmission spectrometer using an equilateral prism as a dispersive element and a flash lamp as a light source was constructed to nondestructively detect the transmission spectrum of duck eggs and monitor the pickling of eggs. The evolution of egg transmittance was highly correlated with the albumen during pickling. The transmittance exponentially decays with time during this period, and the decay rate is related to the pickling rate. The colors of the albumen and yolk remain almost unchanged in the first stage. A multiple linear regression analysis model that realizes a one-to-one association between the days of pickling and the transmission spectra was constructed to determine the pickling duration in the second stage. The coefficient of determination reached 0.88 for a single variable, wavelength, at 590 nm. This method can monitor the maturity of pickled eggs in real time and does not require the evolution of light transmittance.

Nondestructive Detection of the Gel State of Preserved Eggs Based on Dielectric Impedance.

After completing the production of preserved eggs, traditionally, the degree of gelling is judged by allowing workers to tap the preserved eggs with their fingers and sense the resulting oscillations. The amount of oscillation is used for the quality classification. This traditional method produces varying results owing to the differences in the sensitivity of the individual workers, who are not objective. In this study, dielectric detection technology was used to classify the preserved eggs nondestructively. The impedance in the frequency range of 2-300 kHz was resolved into resistance and reactance, and was plotted on a Nyquist diagram. Next, the diagram curve was fitted in order to obtain the equivalent circuit, and the difference in the compositions of the equivalent circuits corresponding to gelled and non-gelled preserved eggs was analyzed. A preserved egg can be considered an RLC series circuit, and its decay rate is consistent with the decay rate given by mechanical vibration theory. The Nyquist diagrams for the resistance and reactance of preserved eggs clearly showed that the resistance and reactance of gelled and non-gelled eggs were quite different, and the classification of the eggs was performed using Bayesian network (BN). The results showed that a BN classifier with two variables, i.e., resistance and reactance, can be used to classify preserved eggs as gelled or non-gelled, with an accuracy of 81.0% and a kappa value of 0.62. Thus, a BN classifier based on resistance and reactance demonstrates the ability to classify the quality of preserved egg gel. This research provides a nondestructive method for the inspection of the quality of preserved egg gel, and provides a theoretical basis for the development of an automated preserved egg inspection system that can be used as the scientific basis for the determination of the quality of preserved eggs.

Use of Modern Regression Analysis in the Dielectric Properties of Foods.

The dielectric properties of food materials is used to describe the interaction of foods with electromagnetic energy for food technology and engineering. To quantify the relationship between dielectric properties and influencing factors, regression analysis is used in our study. Many linear or polynomial regression equations are proposed. However, the basic assumption of the regression analysis is that data with a normal distribution and constant variance are not checked. This study uses sixteen datasets from the literature to derive the equations for dielectric properties. The dependent variables are the dielectric constant and the loss factor. The independent variables are the frequency, temperature, and moisture content. The dependent variables and frequency terms are transformed for regression analysis. The effect of other qualitative factors, such as treatment method and the position of subjects on dielectric properties, are determined using categorical testing. Then, the regression equations can be used to determine which influencing factors are important and which are not. The method can be used for other datasets of dielectric properties to classify influencing factors, including quantitative and qualitative variables.

Quality Assessment during Incubation Using Image Processing.

The fertilized egg is an indispensable production platform for making egg-based vaccines. This study was divided into two parts. In the first part, image processing was employed to analyze the absorption spectrum of fertilized eggs; the results show that the 580-nm band had the most significant change. In the second part, a 590-nm-wavelength LED was selected as the light source for the developed detection device. Using this device, sample images (in RGB color space) of the eggs were obtained every day during the experiment. After calculating the grayscale value of the red layer, the receiver operating characteristic curve was used to analyze the daily data to obtain the area under the curve. Subsequently, the best daily grayscale value for classifying unfertilized eggs and dead-in-shell eggs was obtained. Finally, an industrial prototype of the device designed and fabricated in this study was operated and verified. The results show that the accuracy for detecting unfertilized eggs was up to 98% on the seventh day, with the sensitivity and Youden's index being 82% and 0.813, respectively. On the ninth day, both accuracy and sensitivity reached 100%, and Youden's index reached a value of 1, showing good classification ability. Considering the industrial operating conditions, this method was demonstrated to be commercially applicable because, when used to detect unfertilized eggs and dead-in-shell eggs on the ninth day, it could achieve accuracy and sensitivity of 100% at the speed of five eggs per second.

An Analysis of State-Level Policies and Opioid Overdose Deaths.

Many legislative and regulatory changes have occurred at the state level in response to the opioid crisis in an attempt to decrease overdose deaths. We conducted a negative binomial, regression-based, interrupted time series analysis to evaluate the effects of policies on opioid overdose death counts for 2008-2017 in five Midwestern states: Illinois, Indiana, Kentucky, Michigan, and Ohio. Except for the Good Samaritan laws in Illinois, no single policy change was statistically significant in decreasing overdose deaths. Governmental involvement as a whole was significantly associated with an increase in overdose deaths in Indiana. Policies created to address opioid overdose mortality have had minimal impact in these five Midwestern states. Most of the legislation and regulation that have been created lack educational components for prescribers and community members, which may explain why these policies have not had the intended effect.

Randomized Controlled Theory-Based, E-Mail-Mediated Walking Intervention.

The purpose of this study was to evaluate the ability of two concurrent randomized controlled interventions based on social cognitive theory to increase walking. A second purpose was to compare the efficacy of the intervention between two distinct groups: dog owners and non-dog owners. Adult dog owners ( n = 40) and non-dog owners ( n = 65) were randomized into control or intervention groups. Intervention groups received bi-weekly emails for first 4 weeks and then weekly email for the next 8 weeks targeting self-efficacy, social support, goal setting, and benefits/barriers to walking. Dog owner messages focused on dog walking while non-dog owners received general walking messages. Control groups received a 1-time email reviewing current physical activity guidelines. At 6 months, both intervention groups reported greater increases in walking and maintained these increases at 12 months. The greatest increases were seen in the dog owner intervention group. In conclusion, dog owners accumulated more walking, which may be attributed to the dog-owner relationship.

Evaluation of the Dogs, Physical Activity, and Walking (Dogs PAW) Intervention: A Randomized Controlled Trial.

BACKGROUND: To facilitate physical activity (PA) adoption and maintenance, promotion of innovative population-level strategies that focus on incorporating moderate-intensity lifestyle PAs are needed. OBJECTIVE: The purpose of this randomized controlled trial was to evaluate the Dogs, Physical Activity, and Walking intervention, a 3-month, social cognitive theory (SCT), e-mail-based PA intervention. METHODS: In a longitudinal, repeated-measures design, 49 dog owners were randomly assigned to a control (n = 25) or intervention group (n = 24). The intervention group received e-mail messages (twice weekly for 4 weeks and weekly for 8 weeks) designed to influence SCT constructs of self-efficacy, self-regulation, outcome expectations and expectancies, and social support. At baseline and every 3 months through 1 year, participants completed self-reported questionnaires of individual, interpersonal, and PA variables. Linear mixed models were used to assess for significant differences in weekly minutes of dog walking and theoretical constructs between groups (intervention and control) across time. To test self-efficacy as a mediator of social support for dog walking, tests for mediation were conducted using the bootstrapping technique. RESULTS: With the exception of Month 9, participants in the intervention group accumulated significantly more weekly minutes of dog walking than the control group. On average, the intervention group accumulated 58.4 more minutes (SD = 18.1) of weekly dog walking than the control group (p < .05). Self-efficacy partially mediated the effect of social support variables on dog walking. DISCUSSION: Results indicate that a simple SCT-based e-mail intervention is effective in increasing and maintaining an increase in dog walking among dog owners at 12-month follow-up. In light of these findings, it may be advantageous to design dog walking interventions that focus on increasing self-efficacy for dog walking by fostering social support.

Rapamycin alleviates pathogenesis of a new Drosophila model of ALS-TDP.

TDP-43 is a multi-functional RNA/DNA-binding protein, well-conserved among many species including mammals and Drosophila. However, it is also a major component of the pathological inclusions associated with degenerating motor neurons of amyotrophic lateral sclerosis (ALS). Further, TDP-43 is a signature protein in one subtype of frontotemporal degeneration, FTLD-U. Currently, there are no effective drugs for these neurodegenerative diseases. We describe the generation and characterization of a new fly model of ALS-TDP with transgenic expression of the Drosophila ortholog of TDP-43, dTDP, in adult flies under the control of a temperature-sensitive motor neuron-specific GAL4, thus bypassing the deleterious effect of dTDP during development. Diminished lifespan as well as impaired locomotor activities of the flies following induction of dTDP overexpression have been observed. Dissection of the T1/T2 region of the thoracic ganglia has revealed loss of these neurons. To counter the defects in this fly model of ALS-TDP, we have examined the therapeutic effects of the autophagy activator, rapamycin. Although harmful to the control flies, administration of 400 µM rapamycin before the induction of dTDP overexpression can significantly reduce the number of neurons bearing dTDP (+) aggregates, as well as partially rescue the diminished lifespan and locomotive defects of the ALS-TDP flies. Furthermore, we identify S6K, a downstream mediator of the TOR pathway, as one genetic modifier of dTDP. In sum, this Drosophila model of ALS-TDP under temporal and spatial control presents a useful new genetic tool for the screening and validation of therapeutic drugs for ALS. Furthermore, the data support our previous finding that autophagy activators including rapamycin are potential therapeutic drugs for the progression of neurodegenerative diseases with TDP-43 proteinopathies.

Process dependence of morphology and microstructure of cyanine dye J-aggregate film: correlation with absorption, photo- and electroluminescence properties.

Cyanine dye J-aggregate films are a class of absorbing and luminescent materials which have been extensively applied in the polariton-based research. Here we systematically study the DEDOC cyanine dyes J-aggregate films made by layer-by-layer assembly and spin-coating processes to establish a clear correlation between the film structure and the absorption and luminescence properties. From detailed analyses of morphology, optical spectra, and light-emitting diode characteristics, we demonstrate that layer-by-layer assembled film has higher degrees of homogeneity and molecular packing quality than spin-coated film, leading to a higher absorption coefficient, more uniform luminescence, and a greater electroluminescence quantum efficiency with maximized thickness.

Adjustable exciton-photon coupling with giant Rabi-splitting using layer-by-layer J-aggregate thin films in all-metal mirror microcavities.

Developing of highly absorbing thin films is essential for exploration of light-matter interaction and polariton-based applications. We demonstrate here layer-by-layer assembled J-aggregate thin films of (DEDOC) cyanine dyes that have high absorption coefficient and controlled thicknesses, leading to adjustable exciton-photon coupling and Rabi splitting exceeding 400 meV at room temperature in all-metal mirror microcavities.

Loading effects of anterior cervical spine fusion on adjacent segments.

Adjacent segment degeneration typically follows anterior cervical spine fusion. However, the primary cause of adjacent segment degeneration remains unknown. Therefore, in order to identify the loading effects that cause adjacent segment degeneration, this study examined the loading effects to superior segments adjacent to fused bone following anterior cervical spine fusion. The C3-C6 cervical spine segments of 12 sheep were examined. Specimens were divided into the following groups: intact spine (group 1); and C5-C6 segments that were fused via cage-instrumented plate fixation (group 2). Specimens were cycled between 20° flexion and 15° extension with a displacement control of 1°/second. The tested parameters included the range of motion (ROM) of each segment, torque and strain on both the body and inferior articular process at the superior segments (C3-C4) adjacent to the fused bone, and the position of the neutral axis of stress at under 20° flexion and 15° extension. Under flexion and Group 2, torque, ROM, and strain on both the bodies and facets of superior segments adjacent to the fused bone were higher than those of Group 1. Under extension and Group 2, ROM for the fused segment was less than that of Group 1; torque, ROM, and stress on both the bodies and facets of superior segments adjacent to the fused bone were higher than those of Group 1. These analytical results indicate that the muscles and ligaments require greater force to achieve cervical motion than the intact spine following anterior cervical spine fusion. In addition, ROM and stress on the bodies and facets of the joint segments adjacent to the fused bone were significantly increased. Under flexion, the neutral axis of the stress on the adjacent segment moved backward, and the stress on the bodies of the segments adjacent to the fused bone increased. These comparative results indicate that increased stress on the adjacent segments is caused by stress-shielding effects. Furthermore, increased stress and ROM of the adjacent segments after long-term bone fusion may accelerate degeneration in adjacent segment.

Tai Chi pedicle screw placement for severe scoliosis.

STUDY DESIGN: Retrospective. OBJECTIVE: To evaluate the clinical safety and accuracy of the Tai Chi ((Equation is included in full-text article.)) technique for placing pedicle screws, without intraoperative radiographic imaging, in severe scoliotic spines. SUMMARY OF BACKGROUND DATA: The current techniques for pedicle screw placement have a number of drawbacks in cases of severe scoliosis, including difficulty or impossibility to use, delayed operative time, requiring the presence of trained personnel for the duration of the surgery, high cost issues, increased radiation exposure, and technical challenges. No previous report has described the application of the Tai Chi pedicle screw placement technique for severe scoliosis. MATERIAL AND METHODS: Between 2006 and 2008, the cases of 39 consecutive patients with severe scoliosis (Cobb angle >100 degrees) who underwent posterior correction and stabilization (from T1 to L5) using 992 transpedicular screws were examined. The mean patient age was 25.7 (range, 11 to 63) years at the time of surgery. Pedicle screws were inserted by the Tai Chi technique using anatomic landmarks and preoperative radiographs as a guide. Tai Chi drilling fully utilizes the natural anatomic and physical characteristics of pedicles and unconstrained circular force. By nature, a drill bit driven by unconstrained circular force would migrate within the pedicle along a path of least resistance, advancing along the central cancellous bone tunnel spontaneously. Accurate drilling was achieved by following the nature and sticking to the hand sensation when the drill bit broke through the cancellous bone. The total time for inserting all pedicle screws in each case was recorded. Postoperative computed tomography scans were performed to evaluate the position of the inserted pedicle screws. The screw position was classified as "in" or "out." The distance of perforation was measured. RESULT: The average Cobb angle was 127 degrees (range, 100 to 153 degrees). The number of screws inserted at each level were as follows: T1 (n=10), T2 (n=34), T3 (n=46), T4 (n=53), T5 (n=61), T6 (n=69), T7 (n=75), T8 (n=76), T9 (n=76), T10 (n=77), T11 (n=76), T12 (n=78), L1 (n=77), L2 (n=68), L3 (n=56), L4 (n=38), and L5 (n=22). There were 923 (93%) "in" screws and 69 (7%) "out" screws. The overall accuracy of screw placement was 93%. There were no neurological, vascular, or visceral complications. No screws required postoperative repositioning. The average time for pedicle screw placement was 73 seconds. CONCLUSIONS: Our findings suggest that the Tai Chi pedicle screw placement technique, which does not require intraoperative radiographic imaging, is an accurate, reliable, safe, and time-saving method of placing pedicle screws in severe scoliotic spines.

Neuronal function and dysfunction of Drosophila dTDP.

BACKGROUND: TDP-43 is an RNA- and DNA-binding protein well conserved in animals including the mammals, Drosophila, and C. elegans. In mammals, the multi-function TDP-43 encoded by the TARDBP gene is a signature protein of the ubiquitin-positive inclusions (UBIs) in the diseased neuronal/glial cells of a range of neurodegenerative diseases including amyotrophic lateral sclerosis (ALS) and frontotemporal lobar degeneration (FTLD-U). METHODOLOGY/PRINCIPAL FINDINGS: We have studied the function and dysfunction of the Drosophila ortholog of the mammalian TARDBP gene, dTDP, by genetic, behavioral, molecular, and cytological analyses. It was found that depletion of dTDP expression caused locomotion defect accompanied with an increase of the number of boutons at the neuromuscular junctions (NMJ). These phenotypes could be rescued by overexpression of Drosophila dTDP in the motor neurons. In contrast, overexpression of dTDP in the motor neurons also resulted in reduced larval and adult locomotor activities, but this was accompanied by a decrease of the number of boutons and axon branches at NMJ. Significantly, constitutive overexpression of dTDP in the mushroom bodies caused smaller axonal lobes as well as severe learning deficiency. On the other hand, constitutive mushroom body-specific knockdown of dTDP expression did not affect the structure of the mushroom bodies, but it impaired the learning ability of the flies, albeit moderately. Overexpression of dTDP also led to the formation of cytosolic dTDP (+) aggregates. CONCLUSION/SIGNIFICANCE: These data together demonstrate the neuronal functions of dTDP, and by implication the mammalian TDP-43, in learning and locomotion. The effects of mis-expression of dTDP on Drosophila NMJ suggest that eukaryotic TDP-43 guards against over development of the synapses. The conservation of the regulatory pathways of functions and dysfunctions of Drosophila dTDP and mammalian TDP-43 also shows the feasibility of using the flies as a model system for studying the normal TDP-43 function and TDP-43 proteinopathies in the vertebrates including human.

Evaluation of unilateral cage-instrumented fixation for lumbar spine.

BACKGROUND: To investigate how unilateral cage-instrumented posterior lumbar interbody fusion (PLIF) affects the three-dimensional flexibility in degenerative disc disease by comparing the biomechanical characteristics of unilateral and bilateral cage-instrumented PLIF. METHODS: Twelve motion segments in sheep lumbar spine specimens were tested for flexion, extension, axial rotation, and lateral bending by nondestructive flexibility test method using a nonconstrained testing apparatus. The specimens were divided into two equal groups. Group 1 received unilateral procedures while group 2 received bilateral procedures. Laminectomy, facectomy, discectomy, cage insertion and transpedicle screw insertion were performed sequentially after testing the intact status. Changes in range of motion (ROM) and neutral zone (NZ) were compared between unilateral and bilateral cage-instrumented PLIF. RESULTS: Both ROM and NZ, unilateral cage-instrumented PLIF and bilateral cage-instrumented PLIF, transpedicle screw insertion procedure did not revealed a significant difference between flexion-extension, lateral bending and axial rotation direction except the ROM in the axial rotation. The bilateral group's ROM (-1.7 ± 0. 8) of axial rotation was decreased significantly after transpedicle screw insertion procedure in comparison with the unilateral group (-0.2 ± 0.1). In the unilateral cage-instrumented PLIF group, the transpedicle screw insertion procedure did not demonstrate a significant difference between right and left side in the lateral bending and axial rotation direction. CONCLUSIONS: Based on the results of this study, unilateral cage-instrumented PLIF and bilateral cage-instrumented PLIF have similar stability after transpedicle screw fixation in the sheep spine model. The unilateral approach can substantially reduce exposure requirements. It also offers the biomechanics advantage of construction using anterior column support combined with pedicle screws just as the bilateral cage-instrumented group. The unpleasant effect of couple motion resulting from inherent asymmetry was absent in the unilateral group.

Ribavirin enhances interferon signaling via stimulation of mTOR and p53 activities.

Cellular mechanisms involving the enhancement of interferon (IFN) signaling by ribavirin remain poorly understood. Here, we identified a novel role of ribavirin in the communication between p53 and the mammalian target of rapamycin (mTOR) signaling. Ribavirin activates p53 by stimulating mTOR and promoting the interaction between mTOR and p53. Activated p53 stimulates the transcription of IFN regulatory factor 9 and subsequently enhances IFN signaling. Furthermore, ribavirin-induced activation of mTOR and p53 enhances IFN-dependent signaling for the IFN-alpha/ribavirin combined treatment. We conclude that ribavirin enhances activities of mTOR and p53, which may account for its antiviral and antitumor effects.

Correction hinge in the compromised cord for severe and rigid angular kyphosis with neurologic deficits.

STUDY DESIGN: Retrospective study. OBJECTIVE: To report the use of a reliable and safe technique for the surgical management of severe and rigid angular kyphotic deformities with neurologic deficits. SUMMARY OF BACKGROUND DATA: Severe and rigid angular kyphotic deformity can result in difficult to treat neurologic deficits. Previously described techniques are an ordeal for both the patient and the surgeon and run the risk of damaging the compromised spinal cord because of stretch, compression, deformation, and direct intraoperative cord manipulation during the procedure. METHODS: Seventeen consecutive patients with neurologic deficits due to severe and rigid angular kyphotic deformity were treated with circumferential neurologic decompression and correction by one-shot in situ cantilever bending at the apex of the deformity with a fixed hinge in the compromised spinal cord. The procedure involved minimal manipulation, stretching, compression, and deformation of the vulnerable cord. Minimum follow-up after surgery was 2 years (range: 2.5-6.4 years). Mean Cobb angle of kyphotic deformity was 105.3 degrees (range: 85 degrees -121 degrees ). All patients exhibited neurologic deficits. There were 6, 7, and 4 patients classified as Frankel B, C, and D, respectively. Etiologic diagnoses were congenital kyphosis in 6 and postinfectious kyphosis in 11 patients. RESULTS: Mean operation time was 194 minutes and average blood loss was 1621 mL. All patients showed neurologic improvement. Two of the Frankel B patients improved to Frankel E and 2 each to Frankel D and C. Two of the Frankel C patients improved to Frankel D, whereas 5 improved to Frankel E. All Frankel D patients improved to Frankel E. Kyphotic deformity correction was 30% in the sagittal plane. Complications were minor. CONCLUSION: Circumferential neurologic decompression and one-shot cantilever bending correction with a fixed hinge in the compromised cord is a safe and effective alternative for surgical treatment of severe and rigid angular kyphotic deformities with neurologic deficits.

Closing-opening wedge osteotomy for the treatment of sagittal imbalance.

STUDY DESIGN: Closing-opening wedge osteotomy (COWO) had been performed by the senior author (K.C.) since 1998. A study had been conducted to evaluate the efficacy of COWO since 2000. OBJECTIVE: Assess COWO for sagittal imbalance requiring more than 35 degrees lordotic correction at the level of osteotomy. SUMMARY OF BACKGROUND DATA: Correction of sagittal imbalance commonly uses pedicle subtraction osteotomy or closing wedge osteotomy (CWO). Anatomic limitation of 1 vertebral body restricts CWO to approximately 35 degrees of lordosis at the osteotomized vertebra. Further movement often requires over 1 CWO to obtain adequate correction, but can also be achieved using COWO at a single level by fracturing the anterior vertebral cortex. The efficacy of COWO for the treatment of sagittal imbalance is unclear. METHODS: Eighty-three consecutive patients treated for sagittal imbalance with lumbar COWO with a minimum follow-up of 2 years were analyzed. Radiographic analysis included assessment of thoracic kyphosis, lumbar lordosis, lordosis through COWO site, sagittal translation at the site of osteotomy, and sagittal balance. Outcomes analysis used the Scoliosis Research Society questionnaire. Complications and radiographic findings were analyzed. RESULTS: The average increase in lordosis and improved sagittal balance were 81.9 degrees and 17.1 cm. Mean correction through the osteotomy site was 42.2 degrees (range, 31-55 degrees). Sagittal translation occurred in 40% of these patients. No vascular injury occurred. Although 3 patients developed lumbosacral pseudarthrosis, the COWO area was unaffected in all patients. Nine patients developed cephalad junctional kyphosis and 2 patients developed caudad junctional kyphosis. Most patients reported improvement in terms of pain, self-image, and function as well as overall satisfaction with the procedure. CONCLUSION: COWO is a useful procedure for patients with sagittal imbalance requiring more than 35 degrees lordotic correction through the osteotomy site. A worse clinical result is associated with increasing patient comorbidities, pseudarthrosis in lumbosacral fusion, and junctional kyphosis.