Paul Raymond Hunter

Purpose Evaluate the sex difference in perioperative patient-reported outcome measures (PROMs), 12-month PROM risk-factors, and 12-month PROM prediction models for lumbar decompressive surgery. Methods The study included 2938 cases. The primary 12-month PROM was Oswestry Disability Index (ODI), and secondary PROMs were back and leg pain. Other outcomes included 12-month EQ-5D, and 3-month opioid / non-opioid analgesic intake and employment. Twelve-month PROM predictive models were developed with 2008–2022 data and validated on 2023 data. Sex-specific PROM model predictive performance was compared to non-specific models (both sexes in model). Model calibration was by R², and discrimination by area-under-operating-curve (AUC) to predict an acceptable symptom state (ODI ≤ 22%). Results Across seven metrics, an absolute 4–15% more females than males had a poor outcome. The risk-factor effect on 12-month PROMs was equal for each sex; however, females have more PROM risk-factors. Females have higher prevalence of depression/anxiety, rheumatoid arthritis, osteoarthritis, mobility aided, extreme BMI, scoliosis, vertebral body fracture, and more severe and longer duration of preoperative symptoms linked to poorer PROM. In contrast, males have higher prevalence of diabetes and current smokers. Model validation found sex-specific 12-month ODI model predictive performance (R² 40%, 95%CI 0.31–0.48; AUC = 0.815, 95%CI 0.765–0.864) was equivalent to the non-specific model (R² 42%, 95%CI 0.33–0.50; AUC = 0.819, 95%CI 0.770–0.868). Conclusion Compared to males, females had poorer outcomes, more PROM risk-factors, and accelerated age-related thoracolumbar degenerative change. However, a similar proportion of each sex achieves improvement in each outcome metric after surgery. Sex-specific 12-month PROM models are not indicated.

Most previous research about the dangers of extreme weather events was applicable to populations in high-income countries. Data summarising harms related to extreme weather events in low-income settings are lacking. A systematic review thematically summarising evidence about weather event-linked harms and responses in low- and lower-middle-income countries was conducted. Peer-reviewed and grey literature was systematically searched and selected. Data were extracted about harms, responses and outcomes relevant to six WHO building blocks of healthcare systems. Framework analysis was used to identify predominant themes related to harms, responses and the WHO building blocks. In total, 183 reports were included. Flooding and high winds were the most common types of extreme weather events documented. The main community experience themes identified were the displacement of populations and disruption. The main themes identified for health service delivery were vulnerability, disruption and resilience. Documented examples of resilience or recovery were far fewer for all six WHO healthcare system building blocks than descriptions of vulnerability and disruption. Extreme weather events can be highly disruptive and harmful to healthcare systems and communities in LMIC settings that are often already highly vulnerable.

Purpose Information is limited on prediction models for length of stay (LOS), observed clinical reasons for prolonged LOS, and the association of prolonged LOS with outcome metrics after elective lumbar decompressive surgery. Methods We analysed prospectively collected data on 3132 cases with or without instrumented fusion. A prediction model for LOS in hospital was developed with 2008–2022 data and validated on 2023 data. Validation data was used to evaluate LOS model R² and area under the curve (AUC) to discriminate to prolonged LOS. Observed reasons for prolonged LOS were categorised. Prolonged LOS association with unplanned 30-day readmission was evaluated by absolute risk increase (ARI), and association with outpatient physiotherapy session frequency and 12-month Oswestry Disability Index (ODI) by mean difference. Results All-procedure LOS reduced from 3.0 days in 2008 to 1.5 days in 2023. Notable preoperative LOS predictors were fusion, multilevel surgery, mobility aided, ≥ 80 years, ASA 3, diabetes, and female. LOS model R² was 0.19 (95% CI 0.12–0.26) and AUC was 0.64 (95% CI 0.53–0.75). Prolonged LOS occurred in 11.3% (355/3132) with the observed reason for delayed discharge identified as dural tear (2.7%), difficulty to mobilise (1.5%), pain control (1.2%), patient expectation (1.2%), gastrointestinal (0.7%), and miscellaneous (4.1%). Prolonged LOS was associated with unplanned 30-day readmission (ARI 3.5%, p < 0.001), more outpatient physiotherapy (Δ 0.8 sessions, p < 0.001), and poorer 12-month disability (Δ ODI 5.6, p < 0.001). Conclusion LOS was reduced with no reciprocal increase in unplanned 30-day readmission. Safe reduction of LOS requires enhanced recovery after surgery multidisciplinary pathways that focus on LOS risk factors and perioperative complications. Prolonged LOS is associated with poorer outcomes.

Purpose To identify collection methods and perioperative factors linked to 12-month patient-reported outcome measure (PROM) response rate and evaluate the effect of loss to follow-up on PROM results. Methods The study included 2588 elective lumbar decompressive surgery without spinal fusion during 2008–2023. The primary PROM was the Oswestry Disability Index (ODI). The independent effect of PROM collection methods and perioperative factors on 12-month ODI response was examined. The effect of loss to follow-up on 12-month PROM responder results was evaluated with modelled 12-month PROM and with observed 3-month PROM in a group with last ODI response at 3-months. The response rate to 6-month electronic-only collection was evaluated in patients who advocated to also receive electronic questionnaires. Results Proportionally, 70.8% (1832/2588) were 12-month ODI responders, 19.4% (501/2588) provided a last ODI response at 3-months, and 9.9% (255/2588) were ODI non-responders. The PROM collection method linked to the highest 12-month ODI response rate was two attempts each by electronic and postal questionnaire. Important perioperative factors for lower 12-month ODI response were younger age, smoker, ASA grade, physical comorbidities, male, and anxiety/depression. Twelve-month responder PROM results were unchanged (≤ 1% of metric) by the addition of missing values from modelled PROM or last ODI response at 3-months. The 6-month ODI response rate to electronic-only questionnaire was 48% (467/969). Conclusion Combined electronic and postal PROM collection achieved a 78% response rate. Populations at risk of underrepresentation in spinal register 12-month results were identified. Twelve-month PROM results are not significantly affected by 29% missing data.

Introduction Most lumbar decompressive surgery patients experience symptom improvement to 3 months, after which about 13% experience a clinically relevant deterioration. Patient-reported outcome measures (PROMs) are accepted as indicators of clinical outcome, but the earliest timepoint when PROMs stabilise is unknown and few studies have assessed risk factors for symptom deterioration. This study aimed to identify risk factors for symptom deterioration and identify whether 3-month models or observed 3- or 6-month outcomes accurately predict 12-month disability and pain. Methods The development cohort included 1096 prospectively collected discectomy or laminectomy cases with or without single-level fusion from 01/01/2008–31/12/2020 at a single centre. Three-month models were developed using baseline clinical variables and 3-month PROM. The primary 12-month outcome was the Oswestry Disability Index (ODI), and secondary outcomes were back and leg pain. Validation was on 364 cases from 01/01/2021–31/12/2022. Predictive accuracy was evaluated by interclass correlation coefficient (ICC) and by area-under-the-curve (AUC) to classify to a minimal clinically important difference (MCID). MCID concordance rates for observed 3-month and 6-month with 12-month PROM were calculated. Results Three-month predictors of 12-month disability and pain were condition duration, smoking, diabetes, rheumatic disorder, lower limb arthroplasty, mobility aided, underweight (BMI < 18.5 kg/m²), and 3-month PROM. ODI model and observed 3-month ODI had equivalent ICC and AUC values. Observed 3-month ODI ICC was 0.71 [95% confidence intervals (CI) 0.68–0.74] and AUC was 0.83 [95%CI 0.80–0.86]. Observed 6-month ODI ICC was 0.82 [95%CI 0.79–0.85] and AUC was 0.92 [95%CI 0.89–0.95]. MCID concordance for 3-month ODI was 84% and 6-month ODI was 91%. Conclusion Symptom deterioration after 3 months is linked to baseline factors. This study demonstrates that 6-month PROM accurately predict individual patient 12-month disability and pain after 1–2 level discectomy or laminectomy. Fusion surgery requires a minimum 12-month PROM follow-up.

Purpose To evaluate incidental lumbar durotomy incidence and risk-factors, and the association of durotomy with perioperative metrics and patient-reported outcomes. Methods A total 3140 cases of 1–3 level elective decompressive surgery from 2008 to 2023 at a single centre were included. Multivariable analysis was performed on literature derived variables to identify independent risk-factors for durotomy. Absolute difference or absolute risk increase (ARI) between durotomy and non-durotomy perioperative metrics was calculated. The association between durotomy and 3-month or 12-month patient-reported outcome measures was assessed. Results All-procedure durotomy incidence was 4.5% (142/3140). Durotomy risk-factors were age (odds ratio (OR) 1.016, 95% confidence intervals (95% CI) 1.011–1.020), female (OR 1.48, 95% CI 1.26–1.74), number of operative levels (two-level OR 1.81, 95% CI 1.48–2.21; three-level OR 3.18, 95% CI 2.14–4.72), multiple versus no previous operation (OR 1.85, 95% CI 1.11–3.07), and fusion with discectomy versus discectomy (OR 2.36, 95% CI 1.90–2.93). Durotomy was associated with longer length of stay (∆2.4 days, p < 0.001), longer operative time (∆21 min, p < 0.001), and higher rate of iatrogenic nerve injury (ARI 4.3%, p < 0.001), 30-day return to theatre (ARI 5.7%, p < 0.001), and 30-day readmission (ARI 4.4%, p = 0.002). Durotomy was not associated with poorer patient-reported outcomes. Conclusion Dural tears are often under-reported and are associated with longer hospital stay, increased operative time, and rare perioperative complications which increase healthcare costs. Dural tears did not, however, detrimentally affect patient-reported disability or pain outcomes.

Background: One of the few studies to estimate infection risk with SARS-CoV-2 in the general population was the UK Office of National Statistics Infection Survey. This survey provided data that allowed us to describe and interpret apparent risk factors for testing positive for SARS-CoV-2 in a period when variants and COVID-19 controls experienced large changes. Method: The ONS published estimates of likelihood of individuals testing positive in two week monitoring periods between 21^st November 2021 and 7^th May 2022, relating this positivity to social and behavioural factors. We applied meta-regression to these estimates of likelihood of testing positive to determine whether the monitored potential risk factors remained constant during the pandemic. Results: Some risk factors had consistent relationship with risk of infection (always protective or always linked to higher risk, throughout monitoring period). Other risk factors had variable relationship with risk of infection, with changes seeming to especially correlate with the emergence of Omicron BA.2 dominance. These variable factors were mask-wearing habits, history of foreign travel, household size, working status (retired or not) and contact with children or persons age over 70. Conclusion: Relevance of some risk factors to likelihood of testing positive for SARS-CoV-2 may relate to reinfection risk, variant infectiousness and status of social distancing regulations.

Most of the 2022 mpox outbreaks in high income countries, which predominantly affected men who have sex with men, peaked less than two months after detection. To stop the outbreaks, people were encouraged to limit new sex partners, take up any offers for smallpox vaccination, and self-isolate. The relative contributions of each of these strategies to outbreak reduction are hard to know. To consider the potential relative efficacy of each of these measures individually, we constructed agent-based models using plausible partnership counts, reasonable behaviour choices and published information about smallpox vaccination uptake rates in the UK context during 2022. Compared to a baseline, no intervention scenario, partner reduction was more effective at preventing generation of secondary cases than the vaccine rollout at the speed that the smallpox vaccine rollout occurred in the UK in 2022. These findings suggest that partner reduction by the most affected community rather than pharmaceutical intervention was largely to credit for causing case numbers to peak as early as they did.