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Cost-Utility Analysis of rhBMP-2 Use in Adult Spinal Deformity Surgery.
No full textStudy designEconomic modeling of data from a multicenter, prospective registry.ObjectiveThe aim of this study was to analyze the cost utility of recombinant human bone morphogenetic protein-2 (BMP) in adult spinal deformity (ASD) surgery.Summary of background dataASD surgery is expensive and presents risk of major complications. BMP is frequently used off-label to reduce the risk of pseudarthrosis.MethodsOf 522 ASD patients with fusion of five or more spinal levels, 367 (70%) had at least 2-year follow-up. Total direct cost was calculated by adding direct costs of the index surgery and any subsequent reoperations or readmissions. Cumulative quality-adjusted life years (QALYs) gained were calculated from the change in preoperative to final follow-up SF-6D health utility score. A decision-analysis model comparing BMP versus no-BMP was developed with pseudarthrosis as the primary outcome. Costs and benefits were discounted at 3%. Probabilistic sensitivity analysis was performed using mixed first-order and second-order Monte Carlo simulations. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates (Alpha = 0.05).ResultsBMP was used in the index surgery for 267 patients (73%). The mean (±standard deviation) direct cost of BMP for the index surgery was 6400. Forty patients (11%) underwent revision surgery for symptomatic pseudarthrosis (BMP group, 8.6%; no-BMP group, 17%; P = 0.022). The mean 2-year direct cost was significantly higher for patients with pseudarthrosis (17,000) than for patients without pseudarthrosis (25,000) (P 52% of patients.ConclusionBMP use was associated with reduction in revisions for symptomatic pseudarthrosis in ASD surgery. Cost-utility analysis suggests that BMP use may be favored in ASD surgery; however, this determination requires further research.Level of evidence2
Decadent Discipline and the Stylistique de l'Existence in French Literature, 1884-1922
No full textDecadence, a loosely defined literary movement in France and England at the fin de siècle, has proved popular for its paradoxes and transvaluations that, according to some critics, destabilize modern binarisms. In this thesis, I survey four works of French Decadent literature and its 20th-century afterlives: J.K. Huysmans’s A Rebours (1884), Jean Lorrain’s Monsieur de Phocas (1901), André Gide’s L’Immoraliste (1902), and Marcel Proust’s Sodome et Gomorrhe (1922). As a guiding analytic, “decadent discipline” points to several governing paradoxes in Decadent literature: the stylistic discipline involved in producing Decadent literature; the ascetic discipline of decadent styles of existence; and the recursivity of decadence-attribution, whereby rejections of decadence, in favor of discipline, are themselves deemed decadent. The writings of Friedrich Nietzsche, Michel Foucault, and Eve Kosofsky Sedgwick guide my analysis, which narrows its scope to the intersection of male homosexuality and religious devotion, while highlighting the centrality of racialized, gendered, and colonial violence to the subject formations depicted in this body of literature. In my conclusion, I engage with recent trends in queer theory and culture. I propose that the recursive attribution typified by decadence applies not only to all the foundational binarisms of modernity, but also to queer identity politics: linguistic rejections of binarisms tend to reify and reproduce the binarisms they purport to oppose. Alternatively, an attention to styles—in our own existences and in art—reveals the singularity of individual experience that eludes binarizing language
Cost Benefit of Implementation of Risk Stratification Models for Adult Spinal Deformity Surgery.
No full textSTUDY DESIGN/SETTING: Retrospective cohort study. OBJECTIVE: Assess the extent to which defined risk factors of adverse events are drivers of cost-utility in spinal deformity (ASD) surgery. METHODS: ASD patients with 2-year (2Y) data were included. Tertiles were used to define high degrees of frailty, sagittal deformity, blood loss, and surgical time. Cost was calculated using the Pearl Diver registry and cost-utility at 2Y was compared between cohorts based on the number of risk factors present. Statistically significant differences in cost-utility by number of baseline risk factors were determined using ANOVA, followed by a generalized linear model, adjusting for clinical site and surgeon, to assess the effects of increasing risk score on overall cost-utility. RESULTS: By 2 years, 31% experienced a major complication and 23% underwent reoperation. Patients with ≤2 risk factors had significantly less major complications. Patients with 2 risk factors improved the most from baseline to 2Y in ODI. Average cost increased by 122,650 per risk factor (R2 = .794). Adjusted generalized linear model demonstrated a significant trend between increasing risk score and increasing cost-utility (r2 = .408, P < .001). CONCLUSIONS: The number of defined patient-specific and surgical risk factors, especially those with greater than two, were associated with increased index surgical costs and diminished cost-utility. Efforts to optimize patient physiology and minimize surgical risk would likely reduce healthcare expenditures and improve the overall cost-utility profile for ASD interventions.Level of evidence: III
Gene-nutrient interactions that impact magnesium homeostasis increase risk for neural tube defects in mice exposed to dolutegravir.
No full textIn 2018, data from a surveillance study in Botswana evaluating adverse birth outcomes raised concerns that women on antiretroviral therapy (ART) containing dolutegravir (DTG) may be at increased risk for neural tube defects (NTDs). The mechanism of action for DTG involves chelation of Mg2+ ions in the active site of the viral integrase. Plasma Mg2+ homeostasis is maintained primarily through dietary intake and reabsorption in the kidneys. Inadequate dietary Mg2+ intake over several months results in slow depletion of plasma Mg2+ and chronic latent hypomagnesemia, a condition prevalent in women of reproductive age worldwide. Mg2+ is critical for normal embryonic development and neural tube closure. We hypothesized that DTG therapy might slowly deplete plasma Mg2+ and reduce the amount available to the embryo, and that mice with pre-existing hypomagnesemia due to genetic variation and/or dietary Mg2+ insufficiency at the time of conception and initiation of DTG treatment would be at increased risk for NTDs. We used two different approaches to test our hypothesis: 1) we selected mouse strains that had inherently different basal plasma Mg2+ levels and 2) placed mice on diets with different concentrations of Mg2+. Plasma and urine Mg2+ were determined prior to timed mating. Pregnant mice were treated daily with vehicle or DTG beginning on the day of conception and embryos examined for NTDs on gestational day 9.5. Plasma DTG was measured for pharmacokinetic analysis. Our results demonstrate that hypomagnesemia prior to conception, due to genetic variation and/or insufficient dietary Mg2+ intake, increases the risk for NTDs in mice exposed to DTG. We also analyzed whole-exome sequencing data from inbred mouse strains and identified 9 predicted deleterious missense variants in Fam111a that were unique to the LM/Bc strain. Human FAM111A variants are associated with hypomagnesemia and renal Mg2+ wasting. The LM/Bc strain exhibits this same phenotype and was the strain most susceptible to DTG-NTDs. Our results suggest that monitoring plasma Mg2+ levels in patients on ART regimens that include DTG, identifying other risk factors that impact Mg2+ homeostasis, and correcting deficiencies in this micronutrient might provide an effective strategy for mitigating NTD risk
What Are Y’all Looking At?: Transness and Durational Performance in the American South in for public view (twenty-four)
No full textWhat Are Y’all Looking At?: Transness and Durational Performance in the AmericanSouth in for public view (twenty-four) is a creative project, centering embodied
performance, moving image, and time, that seeks to explore both the lived experiences
and under-representation of queertrans people in the American South. Using durational
endurance performance, queer memory work, and nonlinear filmmaking installation,
the twenty-four-hour performance for public view (twenty-four) synthesizes ideas on
transness relating to durational and endurance performance, the politics of display of
transness and gender presentation, queer legibility and illegibility, embodied
storytelling via queer memory work, and externalizing interiority. By engaging with
queer theory and southern queertrans community stories and memories, for public view
(twenty-four) exists in a lineage of works that urgently seek reflection on the violence
inflicted upon queertrans bodies in the United States, with a focus on the American
South.</p
Progressive Spinal Kyphosis in the Aging Population.
No full textThoracic kyphosis tends to increase with age. Hyperkyphosis is defined as excessive curvature of the thoracic spine and may be associated with adverse health effects. Hyperkyphosis in isolation or as a component of degenerative kyphoscoliosis has important implications for the surgical management of adult spinal deformity. Our objective was to review the literature on the epidemiology, etiology, natural history, management, and outcomes of thoracic hyperkyphosis. We performed a narrative review of literature on thoracic hyperkyphosis and its implications for adult spinal deformity surgery. Hyperkyphosis has a prevalence of 20% to 40% and is more common in the geriatric population. The cause is multifactorial and involves an interaction between degenerative changes, vertebral compression fractures, muscular weakness, and altered biomechanics. It may be associated with adverse health consequences including impaired physical function, pain and disability, impaired pulmonary function, and increased mortality. Nonoperative management may slow the progression of kyphosis and improve function. Surgery is rarely performed for isolated hyperkyphosis in the elderly due to the associated risk, but is an option when kyphosis occurs in the context of significant deformity. In this scenario, increased thoracic kyphosis influences selection of fusion levels and overall surgical planning. Kyphosis is common in older individuals and is associated with adverse health effects and increased mortality. Current evidence suggests a role for nonoperative therapies in reducing kyphosis and delaying its progression. Isolated hyperkyphosis in the elderly is rarely treated surgically; however, increased thoracic kyphosis as a component of global spinal deformity has important implications for patient selection and operative planning
What does it mean to be affiliated with care?: Delphi consensus on the definition of "unaffiliation" and "specialist" in sickle cell disease.
No full textAccruing evidence reveals best practices for how to help individuals living with Sickle Cell Disease (SCD); yet, the implementation of these evidence-based practices in healthcare settings is lacking. The Sickle Cell Disease Implementation Consortium (SCDIC) is a national consortium that uses implementation science to identify and address barriers to care in SCD. The SCDIC seeks to understand how and why patients become unaffiliated from care and determine strategies to identify and connect patients to care. A challenge, however, is the lack of agreed-upon definition for what it means to be unaffiliated and what it means to be a "SCD expert provider". In this study, we conducted a Delphi process to obtain expert consensus on what it means to be an "unaffiliated patient" with SCD and to define an "SCD specialist," as no standard definition is available. Twenty-eight SCD experts participated in three rounds of questions. Consensus was defined as 80% or more of respondents agreeing. Experts reached consensus that an individual with SCD who is unaffiliated from care is "someone who has not been seen by a sickle cell specialist in at least a year." A sickle cell specialist was defined as someone with knowledge and experience in SCD. Having "knowledge" means: being knowledgeable of the 2014 NIH Guidelines, "Evidence-Based Management of SCD", trained in hydroxyurea management and transfusions, trained on screening for organ damage in SCD, trained in pain management and on SCD emergencies, and is aware of psychosocial and cognitive issues in SCD. Experiences that are expected of a SCD specialist include experience working with SCD patients, mentored by a SCD specialist, regular attendance at SCD conferences, and obtains continuing medical education on SCD every 2 years." The results have strong implications for future research, practice, and policy related to SCD by helping to lay a foundation for an new area of research (e.g., to identify subpopulations of unaffiliation and targeted interventions) and policies that support reaffiliation and increase accessibility to quality care
Aortic dissection and ruptures in adult congenital heart disease in Texas from 2009 to 2019.
No full textObjectivesAcute thoracic aortic dissection and rupture (TADR) has an incidence of 5-7 per 100 000-person years. Today, most children with congenital heart disease (CHD) survive to become adults with congenital heart disease (ACHD). This study evaluates TADR in patients with ACHD in a large, hospitalized patient population over 11 years to evaluate the incidence, risk factors and outcomes associated with TADR.MethodsThis was a retrospective review of the Texas Inpatient Discharge Data Set from 1 January 2009 to 31 December 2019. All non-trauma discharges of patients ≥18 years were included. ACHD discharges were identified by International Classification of Diseases, 9th edition (ICD-9)/10 diagnosis codes. TADR were identified using 2 definitions: TADR1 is an ICD-9/10 code for TADR, and TADR2 is TADR1 with an ICD-9/10 procedure code for aortic intervention. Descriptive, univariate and logistic regression statistics were used.ResultsA total of 22 154 664 eligible discharges were identified, of which 12 584 (0.06%) were TADR1 and a subgroup of 5699 (0.03%) were TADR2. CHD was more prevalent in TADR1 (0.2% vs 0.05%; P ConclusionsACHD discharges had a higher frequency of TADR versus the general population (0.9-1.2 vs 0.3-0.6 per 1000 discharges). There is an indication that CHD confers an increased adjusted odds of TADR. As the ACHD population continues to grow in number as well as age, it will be important to continue to assess the risk of TADR from CHD and how traditional risk factors impact this risk
Cost-effectiveness of adult lumbar scoliosis surgery: an as-treated analysis from the adult symptomatic scoliosis surgery trial with 5-year follow-up.
No full textStudy designLongitudinal comparative cohort.ObjectiveThe purpose of this study is to report on the cost-effectiveness of surgical versus non-surgical treatment for Adult Symptomatic Lumbar Scoliosis (ASLS) using the as-treated data and provide a comparison to previously reported intent-to-treat (ITT) analysis. Adult spinal deformity is a relatively prevalent condition for which surgical treatment has become increasingly common but concerns surrounding complications, revision rates and cost-effectiveness remain unresolved. Of these issues, cost-effectiveness is perhaps the most difficult to quantify as the requisite data is difficult to obtain. The purpose of this study is to report on the cost-effectiveness of surgical versus non-surgical treatment for ASLS using the as-treated data and provide a comparison to previously reported ITT analysis.MethodsPatients with at least 5-year follow-up data within the same treatment arm were included. Data collected every 3 months included use of nonoperative modalities, medications and employment status. Costs for surgeries and non-operative modalities were determined using Medicare Allowable rates. Medication costs were determined using the RedBook and indirect costs were calculated based on the reported employment status and income. Quality-Adjusted Life Years (QALY) was determined using the SF-6D.ResultsOf 226 patients, 195 patients (73 Non-op, 122 Op) met inclusion criteria. At 5 years, 29 (24%) patients in the Op group had a revision surgery of whom two had two revisions and one had three revisions. The cumulative cost for the Op group was 29,124 with a cumulative QALY gain of 0.4. This results in an ICER of $44,033 in favor of Op treatment.ConclusionThis as-treated cost-effectiveness analysis demonstrates that surgical treatment for adult lumbar scoliosis becomes favorable at year-three, 1 year earlier than suggested by a previous intent-to-treat analysis.Level of evidenceII
Combining adult with pediatric patient data to develop a clinical decision support tool intended for children: leveraging machine learning to model heterogeneity.
No full textBackgroundClinical decision support (CDS) tools built using adult data do not typically perform well for children. We explored how best to leverage adult data to improve the performance of such tools. This study assesses whether it is better to build CDS tools for children using data from children alone or to use combined data from both adults and children.MethodsRetrospective cohort using data from 2017 to 2020. Participants include all individuals (adults and children) receiving an elective surgery at a large academic medical center that provides adult and pediatric services. We predicted need for mechanical ventilation or admission to the intensive care unit (ICU). Predictor variables included demographic, clinical, and service utilization factors known prior to surgery. We compared predictive models built using machine learning to regression-based methods that used a pediatric or combined adult-pediatric cohort. We compared model performance based on Area Under the Receiver Operator Characteristic.ResultsWhile we found that adults and children have different risk factors, machine learning methods are able to appropriately model the underlying heterogeneity of each population and produce equally accurate predictive models whether using data only from pediatric patients or combined data from both children and adults. Results from regression-based methods were improved by the use of pediatric-specific data.ConclusionsCDS tools for children can successfully use combined data from adults and children if the model accounts for underlying heterogeneity, as in machine learning models