It has been known for over 100 years that cancers have individual karyotypes and arise only years to decades after initiating carcinogens. However, there is still no coherent theory to explain these definitive characteristics of cancer. The prevailing mutation theory holds that cancers are late because the primary cell must accumulate 3–8 causative mutations to become carcinogenic and that mutations, which induce chromosomal instability (CIN), generate the individual karyotypes of cancers. However, since there is still no proven set of mutations that transforms a normal to a cancer cell, we have recently advanced the theory that carcinogenesis is a form of speciation. This theory predicts carcinogens initiate cancer by inducing aneuploidy, which automatically unbalances thousands of genes and thus catalyzes chain-reactions of progressive aneuploidizations. Over time, these aneuploidizations have two endpoints, either non-viable karyotypes or very rarely karyotypes of new autonomous and immortal cancers. Cancer karyotypes are immortalized despite destabilizing congenital aneuploidy by clonal selections for autonomy—similar to those of conventional species. This theory predicts that the very low probability of converting the karyotype of a normal cell to that of a new autonomous cancer species by random aneuploidizations is the reason for the karyotypic individuality of new cancers and for the long latencies from carcinogens to cancers. In testing this theory, we observed: (1) Addition of mutagenic and non-mutagenic carcinogens to normal human and rat cells generated progressive aneuploidizations months before neoplastic transformation. (2) Sub-cloning of a neoplastic rat clone revealed heritable individual karyotypes, rather than the non-heritable karyotypes predicted by the CIN theory. (3) Analyses of neoplastic and preneoplastic karyotypes unexpectedly identified karyotypes with sets of 3–12 new marker chromosomes without detectable intermediates, consistent with single-step origins. We conclude that the speciation theory explains logically the long latencies from carcinogen exposure and the individuality of cancers. In addition, the theory supports the single-step origins of cancers, because karyotypic autonomy is all-or-nothing. Accordingly, we propose that preneoplastic aneuploidy and clonal neoplastic karyotypes provide more reliable therapeutic indications than current analyses of thousands of mutations.
Introduction: Medicaid coverage is associated with longer appointment wait times, decreased access to care, and poorer health outcomes compared with private insurance across medical subspecialties. The purpose of this study was to evaluate new patient appointment wait times for subspecialty Orthopaedic care based on insurance type and to identify factors influencing these wait times. Methods: Orthopaedic physicians were identified using the American Academy of Orthopaedic Surgeons patient-facing database in the fields of Adult Reconstruction, Foot and Ankle, Hand, Sports Medicine, Spine, Pediatric, and General Orthopaedic surgery. Mystery callers, posing as patients with either Medicaid or Blue Cross/Blue Shield (BCBS) insurance, contacted physicians to request the next available new patient appointment. The business days until the first available new patient appointment were recorded and analyzed using a linear mixed Poisson model. Results: A total of 1,002 phone calls were made to 501 unique physicians in 47 states. Among the 349 physicians meeting inclusion criteria, 37% (n = 130) did not accept Medicaid. Medicaid patients experienced a 10% longer wait for a new patient appointment compared with patients with BCBS (incidence rate ratio: 1.10; CI: 1.05 to 1.15; P < 0.01) with mean wait times of 24.9 business days (SD ± 24) and 19.6 business days (SD ± 23), respectively. Increased waiting times were also associated with academic institutions ( P < 0.01), prolonged call times ( P < 0.01), and specific geographic regions ( P < 0.05). Our model achieved an R-squared value of 0.94, demonstrating strong explanatory power. Conclusion: Patients with Medicaid experience longer wait times and decreased access to care when scheduling an appointment with an Orthopaedic surgeon compared with patients with private insurance. This may be due to reimbursement structures in Medicaid that do not cover the full cost of treatment. Aside from advocating for higher reimbursement rates, telehealth initiatives may help bridge this gap to ensure accessibility to orthopaedic surgery for all patients.
Retrospective cohort study. To understand how preoperative LDL levels, statin intake, and fish oil intake affect rates of pseudarthrosis after single-level and multilevel ACDF. Anterior cervical discectomy and fusion (ACDF) is commonly performed to treat cervical degenerative diseases or injuries causing neck pain, myelopathy, and radiculopathy. Pseudarthrosis following ACDF can lead to persistent symptoms and may require revision surgery. No studies have explored the link between low-density lipoprotein (LDL) levels and statin or fish oil intake on pseudarthrosis in ACDF. Patients undergoing ACDF were identified using TriNetX, a health care database with over 100 million patients. Pseudarthrosis rates following single-level and multilevel ACDF were compared between patients with high versus low LDL within one year before surgery. Pseudarthrosis rates were also compared between patients taking or not taking a statin as well as patients taking or not taking fish oil within six months before surgery. For all analyses, patients underwent propensity score matching in a 1:1 ratio based on relevant demographic factors and comorbidities. Patients with an LDL above 142 mg/dL, compared with below 66 mg/dL, had significantly higher rates of pseudarthrosis at six months, one year, and two years after single-level and multilevel ACDF. Patients not taking a statin or fish oil, compared with those taking a statin or fish oil, respectively, also had significantly higher rates of pseudarthrosis at all time points after multilevel ACDF, but not single-level ACDF. Low LDL levels are associated with reduced rates of pseudarthrosis after single-level and multilevel ACDF. Statin and fish oil intake before surgery are also associated with reduced rates of pseudarthrosis after multilevel, but not single-level ACDF. These associations may be used for preoperative planning, patient optimization, and risk stratification.
Intraosseous injections of bone marrow aspirate concentrate have shown promise in the treatment of bone marrow lesions (BMLs) in the knee. With the wide-awake limited anesthesia no tourniquet (WALANT) technique, intraosseous injections can be performed with the patient under local anesthesia in the procedure room or operating room setting. This article describes 2 techniques to access the BML of interest. The "decompression route" involves drilling through the nearest cortex, and the "biologic route" involves drilling through healthy bone to promote bleeding and the introduction of healthy biologic tissue to the BML.
The far-lateral (FL) approach is a classic neurosurgical technique that enables access to the craniocervical junction, which includes the lower clivus, the anterior foramen magnum, and the first two cervical vertebrae. The FL approach also provides access to the inferior cranial nerves (i.e., CN IX, CN X, CN XI, and CN XII), distal portions of the vertebral artery (VA), and inferior basilar trunk. Recent advances in three-dimensional (3D) technology as well as dissections allow for a better understanding of the spatial relationships between anatomical landmarks and neurovascular structures encountered during neurosurgical procedures. This study aims to create a collection of volumetric models (VMs) obtained from cadaveric dissections that depict the FL approach's relevant anatomy and surgical techniques. We describe the relevant multilayer anatomy involved in the FL approach and discuss modifications of this approach as well. Five embalmed heads and two dry skulls were used to record and simulate the FL approach. Relevant steps and anatomy of the FL approach were recorded using 3D scanning technology (e.g., photogrammetry and structured light scanning) to construct high-resolution VMs. Images and VMs were generated to demonstrate major anatomical landmarks for the FL approach. The interactive models allow for clear visualization of the surgical anatomy and windows in 3D and extended reality, rendering a closer look at the nuances of the topography experienced in the laboratory. VMs can be valuable resources for surgical planning and anatomical education by accurately depicting important landmarks.
With the advent and increased usage of posterior, lateral, and anterior surgical approaches to the craniocervical junction (CCJ), it is essential to have a sound understanding of the osseous, ligamentous, and neurovascular layers of this region as well as their three-dimensional (3D) orientations and functional kinematics. Advances in 3D technology can be leveraged to develop a more nuanced and comprehensive understanding of the CCJ, classically depicted via dissections and sketches. As such, this study aims to illustrate - with the use of 3D technologies - the major anatomical landmarks of the CCJ in an innovative and informative way. Photogrammetry, structured light scanning, and 3D reconstruction of medical images were used to generate these high-resolution volumetric models. A clear knowledge of the critical anatomical structures and morphometrics of the CCJ is crucial for the diagnosis, classification, and treatment of pathologies in this transitional region.
