The Controversy over Price Transparency: Patients and Plastic Surgeons Disagree.

Background: The No Surprises Act (NSA) went into effect on January 1, 2022. This federal law is designed to minimize surprise bills for emergency care, out of network (OON) care, and care for uninsured or self-pay individuals. To achieve these goals, the NSA relies heavily on physicians providing cost estimates to patients prior to administering care. Because healthcare is often price-opaque, this study was conducted to assess physician and patient attitudes toward price transparency in plastic surgery and aesthetic/self-pay medicine. Methods: Two cohorts of providers received a survey asking whether and how their practice offers pricing information prior to a consultation and their views regarding the NSA. Patients who had previously used an online price estimator tool also received a survey regarding their experience and accuracy of estimates received online. Results: Most surveyed providers do not share the costs of their services online, whereas patients had a positive experience when receiving estimates of medical services before consultation. Although many providers cited the inaccuracy of price estimator tools as a reason not to incorporate them into their website, most patients reported that their final cost of service was close to (or even less than) the estimate received online prior to the consultation. Conclusions: This study suggests that price transparency is a patient satisfier. Therefore, plastic surgeons should exercise price transparency to be compliant with federal law and to gain a competitive advantage in the market, as the decision to implement price transparency can be mutually beneficial to patients and providers.

Outcomes After Percutaneous Zadek Osteotomy for Insertional Achilles Tendinopathy.

BACKGROUND: Surgical treatment of insertional Achilles tendinopathy (IAT) historically consists of Achilles tendon debridement with reattachment and excision of the posterosuperior calcaneal prominence with or without a gastrocnemius recession. Zadek osteotomy (ZO) is an alternative to an open midline splitting approach. The purpose of this study was to analyze patient-reported outcomes and complications after percutaneously performed ZO with minimum 2 years' follow-up. METHODS: One hundred eight cases treated with percutaneous ZO with a minimum 2-year follow-up were retrospectively reviewed. Postoperative complications and patient satisfaction were evaluated. Foot Function Index (FFI) and visual analog scale (VAS) scores were recorded at preoperative and follow-up appointments to measure patients' functional outcomes and pain, respectively. RESULTS: Mean follow-up was 41.2 months (range, 24-65). Mean age was 51.8 years (range, 28-81). The mean FFI score improved from 56.1 (range, 47-88) to 11.0 (range, 7-59) postoperatively (P < .001). The mean VAS score improved from 7.7 (range, 5-10) to 0.4 (range, 0-7) postoperatively (P < .001). The overall complication rate was 3.8% (n = 4). Of 104 cases, 98.1% of patients said they were satisfied with their procedure (n = 102) when asked if they were satisfied with their ZO and recovery. CONCLUSION: We found the percutaneous ZO to be a safe and effective intervention for treatment of IAT. At a minimum of 2-year follow-up, this intervention is associated with minimal complications, improved function, reduced pain, and a high rate of patient satisfaction.

Enhancing soil health and nutrient availability for Carrizo citrange (X Citroncirus sp.) through bokashi and biochar amendments: An exploration into indoor sustainable soil ecosystem management.

This study investigated the efficacy of organic soil amendments: bokashi (Bok), biochar (BC), and their combination (Bok_BC) in promoting soil health, nutrient availability, and growth of Carrizo citrange (X Citroncirus sp. Rutaceae, Parentage Citrus sinensis × Poncirus trifoliata) under indoor greenhouse settings. Results indicate significant alterations in soil parameters like total carbon (C), total nitrogen (N), and C:N ratio due to Bok, BC, and Bok_BC treatments. BC treatments boosted total C, while Bok increased total N, compared to controls. A note-worthy 25 % average decrease in C:N ratio was observed with Bok and Bok_BC, nearing the optimal 24:1 C:N for microbial growth. This highlights the potential of waste by-products in balancing nutrient release to benefit soil health and plant development. Analysis of nitrite (NO2-), nitrate (NO3-), and ammonium (NH4-N) levels revealed a dynamic relationship between soil treatments and time. Bok and Bok_BC amendments combined with both fertilizer doses [700 and 1400 Electrical Conductivity, EC] showed an initial NH4-N spike (averaging 1513 and 1288 µg N/g dry, respectively), outperforming control soils (average 503 µg N/g dry). Other key elements like phosphorus, potassium, calcium, and chlorine also experienced initial surges in Bok and Bok_BC soils before declining, suggesting a gradual nutrient release. The concentration of potentially toxic elements remained mostly stable or inconclusive, warranting further exploration. Bok, BC, and Bok_BC treatments considerably influenced germination rate and plant growth. The germination rate averaged 24.2 %, 23 %, and 22.5 % for Bok, BC, and Bok_BC, compared to the 15.9 % control. Plant height increased with Bok, BC, and Bok_BC to 18.4 cm, 18.7 cm, and 16.4 cm, respectively, from the 14.8 cm control. The results remained consistent across fertilizer doses, emphasizing the soil amendments' role in bolstering soil and plant health. In summary, the research underscores the potential of carbon-based amendments like bokashi and biochar in enhancing soil health, reducing reliance on synthetic fertilizers, and fostering sustainable soil ecosystems. The insights are pivotal for advancing sustainable agriculture in indoor greenhouse settings for nursery plant production.

The surgical learning curve for percutaneous Zadek osteotomy for treatment of insertional achilles tendinopathy.

INTRODUCTION: The Zadek Osteotomy has been described as an effective technique for the treatment of insertional Achilles tendinopathy. Recently, this strategy has been modified using minimally invasive techniques. A learning curve has been observed in many minimally invasive procedures in foot and ankle surgery. This retrospective study first intended to evaluate if there is a learning curve associated with the percutaneous Zadek Osteotomy. Further, if a learning curve was observed, we planned to assess the data for associated changes in complications and postoperative outcomes. METHODS: A retrospective analysis of 98 patients who underwent percutaneous Zadek Osteotomy was performed. Patient charts were reviewed for operative times, complications, union rates, and Foot Function Index (FFI) and Visual Analogue Scale (VAS) scores. Analysis of variance was utilized to assess for differences between groups of cases. RESULTS: Patients included 61 females and 37 males. Mean age was 51.28 ± 11.12 (range 28-81) years. Mean follow-up time was 42.07 ± 12.99 (range 24-65) months. Significant increases in operative times were observed in cases 1-14 when compared to cases 15-98 (p < 0.001). Improvements in FFI and VAS scores were observed at final follow-up within each case group (p < 0.001); there were no differences detected in FFI or VAS scores between groups of cases. There was no difference detected in number of complications between intervals of cases. CONCLUSION: A learning curve was observed for the percutaneous Zadek Osteotomy, which was overcome around case 14. This learning curve was only observed in terms of procedure length. A surgeon's level of inexperience with the technique does not appear to affect functional outcomes, nonunion, or need for revision. LEVEL OF EVIDENCE IV: Data will not be deposited in a repository.

Dorsal calcaneal wedge removal in zadek osteotomy: A cadaveric study.

BACKGROUND: Insertional Achilles tendinopathy (IAT) is a common pathology with multiple surgical interventions available for treatment. The Zadek, dorsal closing wedge calcaneal osteotomy (ZO) has been demonstrated to be effective treatment of IAT. There have been various recommendations in the literature as to what measurement of wedge removal should be considered ideal to produce greatest postoperative range of motion (ROM), thus postoperative biomechanical potential. Accordingly, the purpose of this cadaveric study was to assess the range of motion achieved after various measurements of wedge removal by ZO. METHODS: The ZO was performed on six cadaveric specimens. A 7.5 mm and 15 mm wedge osteotomy was marked and sequentially completed on each specimen. Lateral fluoroscopic imaging was utilized to take preoperative and postoperative ROM measurements for each osteotomy. Dorsiflexion (DF) and plantarflexion (PF) ROM arcs were measured for each wedge size and compared by t-test. Effect sizes were calculated by Cohen's d analysis. RESULTS: Maximal DF was 110.87 ± 12.97 deg in the pre-osteotomy state. Removal of a 7.5 mm wedge improved DF by 8 deg to a mean 102.93 ± 13.81 deg (p = 0.08). Removal of a 15 mm wedge improved DF by 16 deg to a mean 95.96 ± 11.41 deg (p = 0.003). Cohen's d and effect size calculation demonstrated a 7.5 mm wedge to have a small effect on DF, while a 15 mm wedge had a medium effect (0.29, 0.52 respectively). Maximal PF did not change significantly amongst the pre-osteotomy, 7.5 mm wedge, or 15 mm wedge positions. ICC was 0.96. CONCLUSION: Based on the results presented in this study, removal of a 15 mm wedge with ZO yields significant and greater improvement in ROM than a 7.5 mm wedge. We hope the current study will better inform preoperative planning for ZO. STUDY TYPE: Prospective Cadaver Study. LEVEL OF EVIDENCE: V.

Recurrent Serotonin Syndrome After Ketamine-assisted Electroconvulsive Therapy: A Case Report and Review of the Literature.

Serotonin (5-HT) syndrome (SS) consists of changes in mental status as well as autonomic and neuromuscular changes. Though not well understood, serotonergic pathways have been implicated in the mechanism of action of electroconvulsive therapy (ECT). Ketamine has been used as an induction agent in ECT and as therapy for treatment-resistant depression. Utilizing a case report and literature review, we explored the underlying serotonergic mechanisms of ECT and ketamine by which a syndrome of serotonin toxicity may be precipitated. We describe the case of a 72-year-old woman who developed recurrent SS on 2 occasions in similar circumstances involving the administration of ketamine for ECT. In our literature review, we found 5 cases in which SS was associated with ECT and 1 case linking ketamine to SS. There is emerging evidence that the mechanism of ECT involves 5-HT1A and 5-HT2A receptors, the same receptors that are involved in SS. ECT can transiently increase the permeability of the blood-brain barrier, leading to increased levels of antidepressants in the brain. ECT can, therefore, enhance 5-HT transmission and the likelihood of SS in the presence of serotonergic agents. The effect of ketamine on 5-HT transmission is mediated by the glutamate α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor. Ketamine increases α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid activity in the medial prefrontal cortex, which leads to downstream 5-HT release through glutamate. Through this mechanism, ketamine can increase 5-HT transmission, leading to SS. To our knowledge, this is the only case report of recurrent SS with concurrent use of ECT and ketamine. As ketamine is frequently used in ECT and many patients undergoing ECT are on serotonergic medications, it is important to recognize ketamine as a potential risk factor for SS. There is no evidence for added efficacy when combining ECT and ketamine. Thus, one should proceed with caution when combining these treatments. The burgeoning use of ketamine in ambulatory settings makes it necessary to elucidate the risks, which we discuss further. More research is needed into the mechanisms of ketamine and ECT, specifically how the combination of these treatments influence 5-HT levels.

Fantasy football points capture performance declines in National Football League offensive skill players following an ankle injury.

Background: The ankle is one of the anatomic sites most frequently injured in National Football League (NFL) players. Ankle injuries have previously been shown to have long-lasting negative impacts, and have been associated with impaired athletic performance. The aim of this study was to use fantasy football points as a metric to evaluate the impact of ankle injuries on NFL offensive skill player performance. Methods: An open-access online database was used to identify NFL players who sustained ankle injuries from 2009 to 2020. Another public online database was used to determine fantasy points and other performance metrics for injured offensive skill players in the seasons before and after their ankle injury. Injured players were matched to a healthy control by position, age, and BMI. Paired T-tests were performed to evaluate performance metrics before and after the ankle injury. An ANCOVA was performed to assess the effect of return to play (RTP) time and injury type on fantasy performance. Results: 303 players with ankle injuries were included. Fantasy output, including average points per game (PPG) and total fantasy points accrued in one season, significantly decreased in the season following a player's ankle injury (p < 0.0001). In running backs, tight ends, and wide receivers, performance significantly decreased in every metric evaluated (p < 0.0001). In quarterbacks, there was no significant change in performance, except for a decrease in the number of games played (p = 0.0033) and in the number of interceptions thrown (p = 0.029). Conclusion: Assessing fantasy football output revealed a decrease in player performance in the season following an ankle injury, especially in route-running players. These results can be used to inform injury prevention and rehabilitation practices in the NFL.

Subtalar Osteochondral Lesions: Diagnosis, Indications, and Prognosis.

Although most commonly found in the knee, elbow, and talar dome, osteochondral lesions can also be found in the subtalar joint and can occur due to either high or low energy trauma. Diagnosis of these lesions in the subtalar joint is typically confirmed with advanced imaging such as computerized tomography and MRI. Although there are a few published case reports, there is otherwise very limited literature on the prevalence, treatment options, prognosis, or outcomes for patients with osteochondral lesions of the subtalar joint, and thus further research is required in this area.

Percutaneous vs Open Zadek Osteotomy for Treatment of Insertional Achilles Tendinopathy and Haglund's Deformity: A Systematic Review.

Background: Percutaneous Zadek osteotomy (ZO) has emerged as a surgical treatment of insertional Achilles tendinopathy (IAT) over the last decade. Existing literature is limited regarding the comparison of this approach with the more established, open ZO technique. This systematic review aims to evaluate and compare the current data on open vs percutaneous ZO approaches to help set evidence-based guidelines. Methods: A systematic literature search was performed using the keywords (Zadek osteotomy) OR (Keck and Kelly osteotomy) OR (dorsal closing wedge calcaneal osteotomy) OR (Haglund Deformity) OR (Haglund Syndrome) OR (Insertional Achilles Tendinopathy) and MeSH terms Osteotomy, Calcaneus, Syndrome, Insertional, Achilles tendon, and Tendinopathy. Our search included the following databases: PubMed, Embase, and the Cochrane Library. The PRISMA protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2009 to 2024 and included the use of open or percutaneous approaches of ZO for the treatment of IAT with at least a 12-month follow-up. The MINORS score criteria were used to evaluate the strength and quality of studies. Results: A total of 17 studies were reviewed, including 611 subjects and 625 ZO procedures. Of these procedures, 81 (11%) subjects had a percutaneous and 544 (89%) subjects had an open ZO. The mean follow-up time was 16.1 months for patients treated with percutaneous ZO and 36.1 months for patients treated with open ZO. Both open and percutaneous studies included in this review showed postoperative improvements in AOFAS, FFI, VISA-A, and VAS scores in patients with IAT. The reported complication rate was 5.8% among patients treated with percutaneous ZO and 10.2% among patients treated with open ZO. Conclusion: Percutaneous ZO is an emerging approach with substantially fewer documented cases compared with the open ZO. Both percutaneous and open ZO appear to be relatively effective treatments for insertional Achilles tendinopathy with Haglund's deformity. The lower complication rates reported for percutaneous ZO is encouraging. Further investigation with more subjects undergoing percutaneous ZO is clearly needed.

Minimally invasive Dorsal cheilectomy and Hallux metatarsophalangeal joint arthroscopy for the treatment of Hallux Rigidus.

BACKGROUND: Minimally invasive dorsal cheilectomy (MIDC) has become a popular alternative to an open approach for treating Hallux Rigidus (HR). To reduce some of the complications related to the MIDC approach, a first metatarsophalangeal (MTP) joint arthroscopy can be performed in addition to address the intra-articular pathology associated with Hallux Rigidus. This study aims to examine the effectiveness of MIDC with first MTP arthroscopy in patients with HR with a minimum 1-year follow-up. METHODS: This was a multicenter retrospective review for adult patients with Coughlin and Shurnass Grade 0-3 who were treated with MIDC and first MTP arthroscopy between 3/1/2020 and 8/1/2022, with at least one year of follow-up data. Demographic information, first MTP range of motion (ROM), visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOXFQ), and EQ-5D-5 L scores were collected. Continuous data was expressed as a mean and standard deviation, categorical data was expressed as a percentage. Wilcoxon Rank Sum test was used to compare continuous variables. All P < 0.05 was considered significant. RESULTS: A total of 31 patients were included in the study. Average follow-up time was 16.5 months (range: 12 to 26.2). There was 1 (3.2%) undersurface EHL tendon tear, 2 (6.5%) conversions to an MTP fusion, and 1 (3.2%) revision cheilectomy and capsular release for MTP joint contracture. There was a significant improvement in patient's ROM in dorsiflexion (50 vs 89.6 degrees, P = 0.002), postoperative VAS pain scores (6.4 vs 2.1, P < 0.001), MOXFQ pain scores (58.1 vs 30.7, P = 0.001), MOXFQ Walking/Standing scores (56.6 vs 20.6, P = 0.001), MOXFQ Social Interaction scores (47.3 vs 19.36, P = 0.002), and MOXFQ Index scores (54.7 vs 22.4, P < 0.001). CONCLUSION: We found that MIDC with first MTP arthroscopy was effective at improving patient-reported outcomes at one year with low complication and revision rates. These results suggest that MIDC with first MTP arthroscopy is an effective treatment for early-stage HR. LEVEL OF EVIDENCE: IV.

Academic productivity correlates with industry earnings in foot and ankle fellowship programs in the United States: A retrospective analysis.

BACKGROUND: The study investigates the connection between academic productivity and industry earnings in foot and ankle orthopedic surgery fellowships. Utilizing metrics like the H-index and Open Payments Database (OPD) data, it addresses a gap in understanding the relationship between scholarly achievements and financial outcomes, providing a basis for further exploration in this specialized medical field. AIM: To elucidate the trends between academic productivity and industry earnings across foot and ankle orthopedic surgery fellowship programs in the United States. METHODS: This study is a retrospective analysis of the relationship between academic productivity and industry earnings of foot and ankle orthopedic surgery fellowships at an individual faculty and fellowship level. Academic productivity was defined via H-index and recorded from the Scopus website. Industry earnings were recorded from the OPD. RESULTS: Forty-eight foot and ankle orthopedic surgery fellowships (100% of fellowships) in the United States with a combined total of 165 physicians (95.9% of physicians) were included. Mean individual physician (n = 165) total life-time earnings reported on the OPD website was United States Dollar (USD) 451430.30 ± 1851084.89 (range: USD 25.16-21269249.85; median: USD 27839.80). Mean physician (n = 165) H-index as reported on Scopus is 14.24 ± 12.39 (range: 0-63; median: 11). There was a significant but weak correlation between individual physician H-index and individual physician total life-time earnings (P < 0.001; Spearman's rho = 0.334) and a significant and moderate positive correlation between combined fellowship H-index and total life-time earnings per fellowship (P = 0.004, Spearman's rho = 0.409). CONCLUSION: There is a significant and positive correlation between academic productivity and industry earnings at foot and ankle orthopedic surgery fellowships in the United States. This observation is true on an individual physician level as well as on a fellowship level.

Single threshold adaptive deep brain stimulation in Parkinson's disease depends on parameter selection, movement state and controllability of subthalamic beta activity.

BACKGROUND: Deep brain stimulation (DBS) is an invasive treatment option for patients with Parkinson's disease. Recently, adaptive DBS (aDBS) systems have been developed, which adjust stimulation timing and amplitude in real-time. However, it is unknown how changes in parameters, movement states and the controllability of subthalamic beta activity affect aDBS performance. OBJECTIVE: To characterize how parameter choice, movement state and controllability interactively affect the electrophysiological and behavioral response to single threshold aDBS. METHODS: We recorded subthalamic local field potentials in 12 patients with Parkinson's disease receiving single threshold aDBS in the acute post-operative state. We investigated changes in two aDBS parameters: the onset time and the smoothing of real-time beta power. Electrophysiological patterns and motor performance were assessed while patients were at rest and during a simple motor task. We further studied the impact of controllability on aDBS performance by comparing patients with and without beta power modulation during continuous stimulation. RESULTS: Our findings reveal that changes in the onset time control the extent of beta power suppression achievable with single threshold adaptive stimulation during rest. Behavioral data indicate that only specific parameter combinations yield a beneficial effect of single threshold aDBS. During movement, action induced beta power suppression reduces the responsivity of the closed loop algorithm. We further demonstrate that controllability of beta power is a prerequisite for effective parameter dependent modulation of subthalamic beta activity. CONCLUSION: Our results highlight the interaction between single threshold aDBS parameter selection, movement state and controllability in driving subthalamic beta activity and motor performance. By this means, we identify directions for the further development of closed-loop DBS algorithms.

Local Field Potentials Predict Motor Performance in Deep Brain Stimulation for Parkinson's Disease.

BACKGROUND: Deep brain stimulation (DBS) is an effective treatment option for patients with Parkinson's disease (PD). However, clinical programming remains challenging with segmented electrodes. OBJECTIVE: Using novel sensing-enabled neurostimulators, we investigated local field potentials (LFPs) and their modulation by DBS to assess whether electrophysiological biomarkers may facilitate clinical programming in chronically implanted patients. METHODS: Sixteen patients (31 hemispheres) with PD implanted with segmented electrodes in the subthalamic nucleus and a sensing-enabled neurostimulator were included in this study. Recordings were conducted 3 months after DBS surgery following overnight withdrawal of dopaminergic medication. LFPs were acquired while stimulation was turned OFF and during a monopolar review of both directional and ring contacts. Directional beta power and stimulation-induced beta power suppression were computed. Motor performance, as assessed by a pronation-supination task, clinical programming and electrode placement were correlated to directional beta power and stimulation-induced beta power suppression. RESULTS: Better motor performance was associated with stronger beta power suppression at higher stimulation amplitudes. Across directional contacts, differences in directional beta power and the extent of stimulation-induced beta power suppression predicted motor performance. However, within individual hemispheres, beta power suppression was superior to directional beta power in selecting the contact with the best motor performance. Contacts clinically activated for chronic stimulation were associated with stronger beta power suppression than non-activated contacts. CONCLUSIONS: Our results suggest that stimulation-induced ß power suppression is superior to directional ß power in selecting the clinically most effective contact. In sum, electrophysiological biomarkers may guide programming of directional DBS systems in PD patients. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Behavior genetics and randomized controlled trials: A misleading analogy.

Madole & Harden argue that just as the results of randomized controlled trials (RCTs) represent gains in causal knowledge and are useful, despite their limitations, so too are the findings of human behavior genetics. We argue that this analogy is misleading. Unlike RCTs, the results of human behavior genetics research cannot suggest efficacious interventions, nor point toward future research.

Development and Validation of a Photonumeric Scale for Evaluation of Lip Fullness.

BACKGROUND: The shape, proportion, and fullness of one's lips are associated with overall facial beauty and attractiveness. Lip augmentation, due to personal preference or to reverse natural aging, has become a standard clinical procedure to improve lip volume or proportion. Several options are available to redefine the lips. To objectively evaluate treatment-related improvements in clinical practice and research, a validated photonumeric scale is needed. OBJECTIVE: To present scale-development methods for the Merz Lip Fullness Assessment Scale (MLFAS) and establish its reliability. METHODS: A 5-point photonumeric scale was developed to objectively assess loss of lip volume using male and female subjects of various ages and skin types. To establish intra- and interrater reliability, 8 board-certified dermatologists and plastic surgeons evaluated 64 subjects live in 2 sessions, 2 weeks apart. RESULTS: The weighted kappa for intra- and interrater agreement were ≥ 0.6 in all cases. Intrarater agreement between the 2 rating sessions was nearly perfect (median weighted kappa = 0.911 and 0.930 for the upper lip and lower lip, respectively). Substantial interrater agreement between each rater pair was also demonstrated for both rating sessions, and ratings of upper and lower lip fullness showed comparable reliability. CONCLUSION: The MLFAS is a validated and reliable photonumeric scale for rating loss in lip volume. The scale maintains its reliability with reproducible results across a diverse group of males and females of various ages and Fitzpatrick skin types. J Drugs Dermatol. 2023;22(3): doi:10.36849/JDD.7309.