Cost consequence analysis of waiting for lumbar disc herniation surgery.

The economic repercussions of waiting for lumbar disc surgery have not been well studied. The primary goal of this study was to perform a cost-consequence analysis of patients receiving early vs late surgery for symptomatic disc herniation from a societal perspective. Secondarily, we compared patient factors and patient-reported outcomes. This is a retrospective analysis of prospectively collected data from the CSORN registry. A cost-consequence analysis was performed where direct and indirect costs were compared, and different outcomes were listed separately. Comparisons were made on an observational cohort of patients receiving surgery less than 60 days after consent (short wait) or 60 days or more after consent (long wait). This study included 493 patients with surgery between January 2015 and October 2021 with 272 patients (55.2%) in the short wait group and 221 patients (44.8%) classified as long wait. There was no difference in proportions of patients who returned to work at 3 and 12-months. Time from surgery to return to work was similar between both groups (34.0 vs 34.9 days, p = 0.804). Time from consent to return to work was longer in the longer wait group corresponding to an additional $11,753.10 mean indirect cost per patient. The short wait group showed increased healthcare usage at 3 months with more emergency department visits (52.6% vs 25.0%, p < 0.032), more physiotherapy (84.6% vs 72.0%, p < 0.001) and more MRI (65.2% vs 41.4%, p < 0.043). This corresponded to an additional direct cost of $518.21 per patient. Secondarily, the short wait group had higher baseline NRS leg, ODI, and lower EQ5D and PCS. The long wait group had more patients with symptoms over 2 years duration (57.6% vs 34.1%, p < 0.001). A higher proportion of patients reached MCID in terms of NRS leg pain at 3-month follow up in the short wait group (84.0% vs 75.9%, p < 0.040). This cost-consequence analysis of an observational cohort showed decreased costs associated with early surgery of $11,234.89 per patient when compared to late surgery for lumbar disc herniation. The early surgery group had more severe symptoms with higher healthcare utilization. This is counterbalanced by the additional productivity loss in the long wait group, which likely have a more chronic disease. From a societal economic perspective, early surgery seems beneficial and should be promoted.

Prediction of 2-year clinical outcome trajectories in patients undergoing anterior cervical discectomy and fusion for spondylotic radiculopathy.

OBJECTIVE: Anterior cervical discectomy and fusion (ACDF) is often described as the gold standard surgical technique for cervical spondylotic radiculopathy. Although outcomes are considered favorable, there is little prognostic evidence to guide patient selection for ACDF. This study aimed to 1) describe the 24-month postoperative trajectories of arm pain, neck pain, and pain-related disability; and 2) identify perioperative prognostic factors that predict trajectories representing poor clinical outcomes. METHODS: In this retrospective cohort study, patients with cervical spondylotic radiculopathy who underwent ACDF at 1 of 12 orthopedic or neurological surgery centers were recruited. Potential outcome predictors included demographic, health, clinical, and surgery-related prognostic factors. Surgical outcomes were classified by trajectories of arm pain intensity, neck pain intensity (numeric pain rating scales), and pain-related disability (Neck Disability Index) from before surgery to 24 months postsurgery. Trajectories of postoperative pain and disability were estimated with latent class growth analysis, and prognostic factors associated with poor outcome trajectory were identified with robust Poisson models. RESULTS: The authors included data from 352 patients (mean age 50.9 [SD 9.5] years; 43.8% female). The models estimated that 15.5%-23.5% of patients followed a trajectory consistent with a poor clinical outcome. Lower physical and mental health-related quality of life, moderate to severe risk of depression, and longer surgical wait time and procedure time predicted poor postoperative trajectories for all outcomes. Receiving compensation and smoking additionally predicted a poor neck pain outcome. Regular exercise, physiotherapy, and spinal injections before surgery were associated with a lower risk of poor disability outcome. Patients who used daily opioids, those with worse general health, or those who reported predominant neck pain or a history of depression were at greater risk of poor disability outcome. CONCLUSIONS: Patients who undergo ACDF for cervical spondylotic radiculopathy experience heterogeneous postoperative trajectories of pain and disability, with 15.5%-23.5% of patients experiencing poor outcomes. Demographic, health, clinical, and surgery-related prognostic factors can predict ACDF outcomes. This information may further assist surgeons with patient selection and with setting realistic expectations. Future studies are needed to replicate and validate these findings prior to confident clinical implementation.

Metatarsal bars more effective than metatarsal pads in reducing impulse on the second metatarsal head.

BACKGROUND: The second metatarsal head is commonly involved in cases of metatarsalgia. As part of the conservative treatment, metatarsal bars and metatarsal pads are often prescribed. OBJECTIVE: To compare the effectiveness of metatarsal bars and metatarsal pads in reducing impulse on the second metatarsal head. METHOD: Thirty-five healthy subjects were monitored with an insole scanning system during walking in four different conditions: (a) wearing shoes only, (b) shoes plus metatarsal pads and shoes plus metatarsal bars, placed either (c) perpendicular to the foot axis or (d) oblique to the foot axis. The impulse under the second metatarsal head was measured using the first condition as a control. Both feet were examined in each subject resulting in a total of 840 measurements. RESULTS: Both metatarsal bars and metatarsal pads were effective in reducing impulse when compared with the control (P<0.01). Metatarsal bars were found to be more effective in reducing impulse as compared to the metatarsal pads (P<0.01), and the oblique position of the bars was more effective than the perpendicular one (P<0.01). CONCLUSIONS: The greatest reduction of impulse on the second metatarsal head in healthy subjects is achieved with the use of metatarsal bars in an oblique position.

Generalized structure and evolution of ITS1 and ITS2 rDNA in black flies (Diptera: Simuliidae).

A sample of 15 Nearctic black fly species spread over five genera is used to perform the first systematic study of the internal transcribed spacer 1 (ITS1) from the nuclear rDNA transcription unit of Simuliidae. ITS1 from the Prosimuliini tribe is a conserved, repeat-free and highly structured sequence of about 490 nucleotides (nt), while Simuliini exhibit a medium-sized or short version, the latter minimally 95 nt long. All size versions possess a common 39 nt core made from eight short blocks interspersed among highly variable sequences. Conversely, that variability which generally excludes ITS1 from phylogenetic applications translates for many species into polymorphisms suggesting the general feasibility of ITS1-based population studies. We show in a parallel investigation that ITS2, the other rDNA transcribed spacer, is length-constrained around 270 nt and possesses a three-domain fold anchored by four conserved regions representing about 40% of the whole sequence. An alignment guided by this secondary structure leads to a phylogeny, derived through the GTR model, which convincingly displays the basal divergence between Simuliini and Prosimuliini. However, the poorer support of some intermediate nodes could indicate rapid divergence events within Simulium.

A molecular revision of the taxonomic status of mermithid parasites of black flies from Quebec (Canada).

The four currently recognized mermithid (Nematoda) species parasitizing black flies (Diptera: Simuliidae) from Northeast America were distinguished using discriminatory PCR primers aimed at COI and 18S rDNA. Isomermis wisconsinensis, Gastromermis viridis and Mesomermis camdenensis were easily differentiated using either genomic target, even for juvenile mermithids damaged beyond morphological recognition. However, specimens from Mesomermis flumenalis being identical in external morphology and producing a unique-sized PCR product were classified by sequence data into four clearly distinguished molecular variants. This quartet was made of two winter and two summer 'physiological variants', including one which also belonged to, but diverged early from the rest of the Mesomermis genus. Combining the multiplex PCR and sequencing approaches allowed for the characterization of a multiple parasitism which simultaneously implicated I. wisconsinensis and two M. flumenalis variants. With another instance where parasites were identified by morphology only, this is the first report of black fly parasitism by multiple mermithid species. A phylogenetic tree built by combining our sequences to previous GenBank entries likely indicates a monophyletic origin for the mermithid family, but also suggests that differentiation between parasite genera sometimes occurred before the evolutionary emergence of the actual host group.

Distal anatomical relationship of the flexor hallucis longus and flexor digitorum longus tendons.

BACKGROUND: The distal attachment of the flexor hallucis longus (FHL) tendon with the flexor digitorum longus (FDL) tendon varies antomically. The presence of a strong link between the two tendons can preserve distal function if one of the tendons is used for transfer. METHODS: Twenty-four cadaver legs were dissected, and the distal relationship of the FHL tendon with the FDL tendon was analyzed. The width of the tendons and their attachments were measured to the closest 0.5 mm. RESULTS: Three different configurations were found. In type 1, a tendinous slip branched from the FHL to the FDL (10 of 24 feet). In type 2, a slip branched from the FHL to the FDL and another from the FDL to FHL (10 of 24). In type 3, no attachment was present (four of 24). In four cadavers the attachment was different in the right and left feet. CONCLUSION AND CLINICAL RELEVANCE: The absence of a cross connection between the two tendons in the foot may be more frequent than previously reported. Three configurations of the anatomical relationship of the distal FDL to FHL tendons were found in this study with a small sample size. Based on these findings, to preserve the distal function of the FDL after transfer of the proximal FDL tendon, routine tenodesis should be done or a wider exposure and tenodesis in type 3 variations.

Characterization and authentication of insect cell lines using RAPD markers.

Random amplified polymorphic DNA (RAPD) analysis was used to characterize 11 insect cell lines, including six from lepidoptera (five species), one from diptera and four from coleoptera (one species: Leptinotarsa decemlineata). Whatever the order and even when comparing two closely related species from the same genus (Spodoptera), the DNA fingerprints are very different from one species or from one primer to the other. On the other hand, two independently isolated cell lines from the lepidopteran Phthorimaea operculella produce nearly identical profiles with only minor differences. Finally, a statistical analysis based on Nei's similarity coefficient was performed on the fingerprints of four independent cell lines from the Colorado potato beetle, L. decemlineata. Each possesses a common recognizable pattern also found in field-collected insects, while also showing a series of polymorphic markers which allow one to distinguish each cell line from the three others. RAPD fingerprinting, together with the use of appropriate statistics, thus constitutes a highly specific method both for the authentication of the species from which a cell line was developed and for the individual characterization of each cell line from a given species.