Comparison of the Efficacy of Caudal, Interlaminar, and Transforaminal Epidural Injections in Managing Lumbar Disc Herniation: Is One Method Superior to the Other?

Background: Epidural injections are performed utilizing 3 approaches in the lumbar spine: caudal, interlaminar, and transforaminal. The literature on the efficacy of epidural injections has been sporadic. There are few high-quality randomized trials performed under fluoroscopy in managing disc herniation that have a long-term follow-up and appropriate outcome parameters. There is also a lack of literature comparing the efficacy of these 3 approaches. Methods: This manuscript analyzes data from 3 randomized controlled trials that assessed a total of 360 patients with lumbar disc herniation. There were 120 patients per trial either receiving local anesthetic alone (60 patients) or local anesthetic with steroids (60 patients). Results: Analysis showed similar efficacy for caudal, interlaminar, and transforaminal approaches in managing chronic pain and disability from disc herniation. The analysis of caudal epidural injections showed the potential superiority of steroids compared with local anesthetic alone a 2-year follow-up, based on the average relief per procedure. In the interlaminar group, results were somewhat superior for pain relief in the steroid group at 6 months and functional status at 12 months. Interlaminar epidurals provided improvement in a significantly higher proportion of patients. The proportion of patients nonresponsive to initial injections was also lower in the group for local anesthetic with steroid in the interlaminar trial. Conclusions: The results of this assessment show significant improvement in patients suffering from chronic lumbar disc herniation with 3 lumbar epidural approaches with local anesthetic alone, or using steroids with long-term follow-up of up to 2 years, in a contemporary interventional pain management setting

Retrospective cohort study of usage patterns of epidural injections for spinal pain in the US fee-for-service Medicare population from 2000 to 2014

Objective: To assess the usage patterns of epidural injections for chronic spinal pain in the fee-for-service (FFS) Medicare population from 2000 to 2014 in the USA. Design: A retrospective cohort. Methods: The descriptive analysis of the administrative database from Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) master data from 2000 to 2014 was performed. The guidance from Strengthening the Reporting of Observational studies in Epidemiology (STROBE) was applied. Analysis included multiple variables based on the procedures, specialties and geography. Results: Overall epidural injections increased 99% per 100 000 Medicare beneficiaries with an annual increase of 5% from 2000 to 2014. Lumbar interlaminar and caudal epidural injections constituted 36.2% of all epidural injections, with an overall decrease of 2% and an annual decrease of 0.2% per 100 000 Medicare beneficiaries. However, lumbosacral transforaminal epidural injections increased 609% with an annual increase of 15% from 2000 to 2014 per 100 000 Medicare population. Conclusions: Usage of epidural injections increased from 2000 to 2014, with a decline thereafter. However, an escalating growth has been seen for lumbosacral transforaminal epidural injections despite numerous reports of complications and regulations to curb the usage of transforaminal epidural injections

The California-Kepler Survey. II. Precise Physical Properties of 2025 Kepler Planets and Their Host Stars

We present stellar and planetary properties for 1305 Kepler Objects of Interest (KOIs) hosting 2025 planet candidates observed as part of the California-Kepler Survey. We combine spectroscopic constraints, presented in Paper I, with stellar interior modeling to estimate stellar masses, radii, and ages. Stellar radii are typically constrained to 11%, compared to 40% when only photometric constraints are used. Stellar masses are constrained to 4%, and ages are constrained to 30%. We verify the integrity of the stellar parameters through comparisons with asteroseismic studies and Gaia parallaxes. We also recompute planetary radii for 2025 planet candidates. Because knowledge of planetary radii is often limited by uncertainties in stellar size, we improve the uncertainties in planet radii from typically 42% to 12%. We also leverage improved knowledge of stellar effective temperature to recompute incident stellar fluxes for the planets, now precise to 21%, compared to a factor of two when derived from photometry.Comment: 13 pages, 4 figures, 4 tables, accepted for publication in AJ; full versions of tables 3 and 4 are include

The California-Kepler Survey V. Peas in a Pod: Planets in a Kepler Multi-planet System are Similar in Size and Regularly Spaced

We have established precise planet radii, semimajor axes, incident stellar fluxes, and stellar masses for 909 planets in 355 multi-planet systems discovered by Kepler. In this sample, we find that planets within a single multi-planet system have correlated sizes: each planet is more likely to be the size of its neighbor than a size drawn at random from the distribution of observed planet sizes. In systems with three or more planets, the planets tend to have a regular spacing: the orbital period ratios of adjacent pairs of planets are correlated. Furthermore, the orbital period ratios are smaller in systems with smaller planets, suggesting that the patterns in planet sizes and spacing are linked through formation and/or subsequent orbital dynamics. Yet, we find that essentially no planets have orbital period ratios smaller than $1.2$, regardless of planet size. Using empirical mass-radius relationships, we estimate the mutual Hill separations of planet pairs. We find that $93\%$ of the planet pairs are at least 10 mutual Hill radii apart, and that a spacing of $\sim20$ mutual Hill radii is most common. We also find that when comparing planet sizes, the outer planet is larger in $65 \pm 0.4\%$ of cases, and the typical ratio of the outer to inner planet size is positively correlated with the temperature difference between the planets. This could be the result of photo-evaporation.Comment: Published in The Astronomical Journal. 15 pages, 17 figure

The California-Kepler Survey. I. High Resolution Spectroscopy of 1305 Stars Hosting Kepler Transiting Planets

The California-Kepler Survey (CKS) is an observational program to improve our knowledge of the properties of stars found to host transiting planets by NASA's Kepler Mission. The improvement stems from new high-resolution optical spectra obtained using HIRES at the W. M. Keck Observatory. The CKS stellar sample comprises 1305 stars classified as Kepler Objects of Interest, hosting a total of 2075 transiting planets. The primary sample is magnitude-limited (Kp < 14.2) and contains 960 stars with 1385 planets. The sample was extended to include some fainter stars that host multiple planets, ultra short period planets, or habitable zone planets. The spectroscopic parameters were determined with two different codes, one based on template matching and the other on direct spectral synthesis using radiative transfer. We demonstrate a precision of 60 K in effective temperature, 0.10 dex in surface gravity, 0.04 dex in [Fe/H], and 1.0 km/s in projected rotational velocity. In this paper we describe the CKS project and present a uniform catalog of spectroscopic parameters. Subsequent papers in this series present catalogs of derived stellar properties such as mass, radius and age; revised planet properties; and statistical explorations of the ensemble. CKS is the largest survey to determine the properties of Kepler stars using a uniform set of high-resolution, high signal-to-noise ratio spectra. The HIRES spectra are available to the community for independent analyses.Comment: 20 pages, 19 figures, accepted for publication in AJ; a full version of Table 5 is included as tab_cks.csv and tab_cks.te

Cost Utility Analysis of Cervical Therapeutic Medial Branch Blocks in Managing Chronic Neck Pain

Background:Controlled diagnostic studies have established the prevalence of cervical facet joint pain to range from 36% to 67% based on the criterion standard of ≥ 80% pain relief. Treatment of cervical facet joint pain has been described with Level II evidence of effectiveness for therapeutic facet joint nerve blocks and radiofrequency neurotomy and with no significant evidence for intraarticular injections. However, there have not been any cost effectiveness or cost utility analysis studies performed in managing chronic neck pain with or without headaches with cervical facet joint interventions. Study Design:Cost utility analysis based on the results of a double-blind, randomized, controlled trial of cervical therapeutic medial branch blocks in managing chronic neck pain. Objectives:To assess cost utility of therapeutic cervical medial branch blocks in managing chronic neck pain. Methods: A randomized trial was conducted in a specialty referral private practice interventional pain management center in the United States. This trial assessed the clinical effectiveness of therapeutic cervical medial branch blocks with or without steroids for an established diagnosis of cervical facet joint pain by means of controlled diagnostic blocks. Cost utility analysis was performed with direct payment data for the procedures for a total of 120 patients over a period of 2 years from this trial based on reimbursement rates of 2016. The payment data provided direct procedural costs without inclusion of drug treatments. An additional 40% was added to procedural costs with multiplication of a factor of 1.67 to provide estimated total costs including direct and indirect costs, based on highly regarded surgical literature. Outcome measures included significant improvement defined as at least a 50% improvement with reduction in pain and disability status with a combined 50% or more reduction in pain in Neck Disability Index (NDI) scores. Results:The results showed direct procedural costs per one-year improvement in quality adjusted life year (QALY) of United States Dollar (USD) of $2,552, and overall costs of USD$4,261. Overall, each patient on average received 5.7 ± 2.2 procedures over a period of 2 years. Average significant improvement per procedure was 15.6 ± 12.3 weeks and average significant improvement in 2 years per patient was 86.0 ± 24.6 weeks. Limitations:The limitations of this cost utility analysis are that data are based on a single center evaluation. Only costs of therapeutic interventional procedures and physician visits were included, with extrapolation of indirect costs. Conclusion:The cost utility analysis of therapeutic cervical medial branch blocks in the treatment of chronic neck pain non-responsive to conservative management demonstrated clinical effectiveness and cost utility at USD $4,261 per one year of QALY

Are Honest People More Rational? Associations Between Personality and Decision-Making

The HEXACO personality framework is an emerging perspective to explain the phenotypic structure of personality, and is believed to replicate across natural language lexical studies better than the Five-Factor Model. Although similar to the “Big Five,” the primary difference between the two structural models is the recovery of the Honesty-Humility dimension, a dimension related to sincerity, fairness, and modesty. This trait has also been associated with behavioral under-control and increased risk-taking, but its association with rational responding has yet to be explicated. In the current study, we test the associations between HEXACO personality dimensions and decision-making competence (DMC), a variable that reflects individual differences in rational responding across several classic behavioral decision-making tasks (e.g., framing effects and following decision rules; Parker & Fischhoff, 2005). DMC has been shown to predict health behaviors and risk attitudes; however, little research has been conducted to examine the association between DMC and broad dispositional traits. Based on past research, we predicted that Honesty-Humility, Conscientiousness, and Openness, would be significantly associated with greater DMC. We recruited an online Italian community sample (n=804). Participants completed the HEXACO-PI-R questionnaire (Ashton & Lee, 2009) and subscales of the Italian-language DMC (del Missier et al., 2012). As expected, we found significant correlations for Honesty/Humility, r = .21, p < .01, Conscientiousness r = .28, p < .01, and Openness r = .17, p < .01. Extraversion, Agreeableness, and Emotionality (i.e., Neuroticism), was not related to DMC performance. Multiple regression analysis revealed that the six HEXACO dimensions accounted for 12% variance on DMC. Examining these associations at the facet-level, we found that for Honesty-Humility, that traits related to Honesty were associated with DMC scores, but not facets related to Humility. Holding each dimension constant, we found that Conscientiousness, Honesty/Humility and Openness uniquely accounted for variance in DMC scores. These results suggest that certain dispositional traits related to cognitive and behavioral control (e.g., Honesty/Humility and Conscientiousness) and open-minded thinking are associated with a greater tendency to engage in rational thought, which in turn, may be associated with better real-life decision quality

Discovery of a Transiting Adolescent Sub-Neptune Exoplanet with K2

The role of stellar age in the measured properties and occurrence rates of exoplanets is not well understood. This is in part due to a paucity of known young planets and the uncertainties in age-dating for most exoplanet host stars. Exoplanets with well-constrained ages, particularly those which are young, are useful as benchmarks for studies aiming to constrain the evolutionary timescales relevant for planets. Such timescales may concern orbital migration, gravitational contraction, or atmospheric photo-evaporation, among other mechanisms. Here we report the discovery of an adolescent transiting sub-Neptune from K2 photometry of the low-mass star K2-284. From multiple age indicators we estimate the age of the star to be 120 Myr, with a 68% confidence interval of 100-760 Myr. The size of K2-284 b ($R_P$ = 2.8 $\pm$ 0.1 $R_\oplus$) combined with its youth make it an intriguing case study for photo-evaporation models, which predict enhanced atmospheric mass loss during early evolutionary stages.Comment: Accepted to AJ, 36 pages, 17 figures, 5 table

Updated Parameters and a New Transmission Spectrum of HD 97658b

Recent years have seen increasing interest in the characterization of sub-Neptune-sized planets because of their prevalence in the Galaxy, contrasted with their absence in our solar system. HD 97658 is one of the brightest stars hosting a planet of this kind, and we present the transmission spectrum of this planet by combining four Hubble Space Telescope transits, 12 Spitzer/IRAC transits, and eight MOST transits of this system. Our transmission spectrum has a higher signal-to-noise ratio than those from previous works, and the result suggests that the slight increase in transit depth from wavelength 1.1–1.7 μm reported in previous works on the transmission spectrum of this planet is likely systematic. Nonetheless, our atmospheric modeling results are inconclusive, as no model provides an excellent match to our data. Nonetheless, we find that atmospheres with high C/O ratios (C/O ≳ 0.8) and metallicities of ≳100× solar metallicity are favored. We combine the mid-transit times from all of the new Spitzer and MOST observations and obtain an updated orbital period of P = 9.489295 ± 0.000005, with a best-fit transit time center at T₀ = 2456361.80690 ± 0.00038 (BJD). No transit timing variations are found in this system. We also present new measurements of the stellar rotation period (34 ± 2 days) and stellar activity cycle (9.6 yr) of the host star HD 97658. Finally, we calculate and rank the Transmission Spectroscopy Metric of all confirmed planets cooler than 1000 K and with sizes between 1 R⊕ and 4 R⊕. We find that at least a third of small planets cooler than 1000 K can be well characterized using James Webb Space Telescope, and of those, HD 97658b is ranked fifth, meaning that it remains a high-priority target for atmospheric characterization

K2 Discovers a Busy Bee: An Unusual Transiting Neptune Found in the Beehive Cluster

Open clusters have been the focus of several exoplanet surveys but only a few planets have so far been discovered. The \emph{Kepler} spacecraft revealed an abundance of small planets around small, cool stars, therefore, such cluster members are prime targets for exoplanet transit searches. Kepler's new mission, K2, is targeting several open clusters and star-forming regions around the ecliptic to search for transiting planets around their low-mass constituents. Here, we report the discovery of the first transiting planet in the intermediate-age (800 Myr) Beehive cluster (Praesepe). K2-95 is a faint ($\mathrm{Kp = 15.5\,mag}$) $\mathrm{M3.0\pm0.5}$ dwarf from K2's Campaign 5 with an effective temperature of $\mathrm{3471 \pm 124\,K}$, approximately solar metallicity and a radius of $\mathrm{0.402 \pm 0.050 \,R_\odot}$. We detected a transiting planet with a radius of $\mathrm{3.47^{+0.78}_{-0.53} \, R_\oplus}$ and an orbital period of 10.134 days. We combined photometry, medium/high-resolution spectroscopy, adaptive optics/speckle imaging and archival survey images to rule out any false positive detection scenarios, validate the planet, and further characterize the system. The planet's radius is very unusual as M-dwarf field stars rarely have Neptune-sized transiting planets. The comparatively large radius of K2-95b is consistent with the other recently discovered cluster planets K2-25b (Hyades) and K2-33b (Upper Scorpius), indicating systematic differences in their evolutionary states or formation. These discoveries from K2 provide a snapshot of planet formation and evolution in cluster environments and thus make excellent laboratories to test differences between field-star and cluster planet populations.Comment: 14 pages, 8 figues. Accepted for publication in A