Cost-effectiveness of anterior surgical decompression surgery for cervical degenerative disk disease: a systematic review of economic evaluations

PURPOSE

No clear consensus exists on which anterior surgical technique is most cost-effective for treating cervical degenerative disk disease (CDDD). One of the most common treatment options is anterior cervical discectomy with fusion (ACDF). Anterior cervical discectomy with arthroplasty (ACDA) was developed in an effort to reduce the incidence of clinical adjacent segment pathology and associated additional surgeries by preserving motion. This systematic review aims to evaluate the evidence regarding the cost-effectiveness of anterior surgical decompression techniques used to treat radiculopathy and/or myelopathy caused by CDDD.

METHODS

The search was conducted in PubMed, EMBASE, Web of Science, CINAHL, EconLit, NHS-EED and the Cochrane Library. Studies were included if healthcare costs and utility or effectivity measurements were mentioned.

RESULTS

A total of 23 studies were included out of the 1327 identified studies. In 9 of the 13 studies directly comparing ACDA and ACDF, ACDA was the most cost-effective technique, with an incremental cost effectiveness ratio ranging from $2.900/QALY to $98.475/QALY. There was great heterogeneity between the costs of due to different in- and exclusion criteria of costs and charges, cost perspective, baseline characteristics, and calculation methods. The methodological quality of the included studies was moderate.

CONCLUSION

The majority of studies report ACDA to be a more cost-effective technique in comparison with ACDF. The lack of uniform literature impedes any solid conclusions to be drawn. There is a need for high-quality cost-effectiveness research and uniformity in the conduct, design and reporting of economic evaluations concerning the treatment of CDDD.

TRIAL REGISTRATION

PROSPERO Registration: CRD42020207553 (04.10.2020).

Controlling stomatal aperture in semi-arid regions-The dilemma of saving water or being cool?

Stomatal regulation of leaf gas exchange with the atmosphere is a key process in plant adaptation to the environment, particularly in semi-arid regions with high atmospheric evaporative demand. Development of stomata, integrating internal signaling and environmental cues sets the limit for maximum diffusive capacity of stomata, through size and density and is under a complex genetic control, thus providing multiple levels of regulation. Operational stomatal conductance to water vapor and CO2 results from feed-back and/or feed-forward mechanisms and is the end-result of a plethora of signals originated in leaves and/or in roots at each moment. CO2 assimilation versus water vapor loss, proposed to be the subject of optimal regulation, is species dependent and defines the water use efficiency (WUE). WUE has been a topic of intense research involving areas from genetics to physiology. In crop plants, especially in semi-arid regions, the question that arises is how the compromise of reducing transpiration to save water will impact on plant performance through leaf temperature. Indeed, plant transpiration by providing evaporative cooling, is a major component of the leaf energy balance. In this paper we discuss the dilemma of 'saving water or being cool' bringing about recent findings from molecular genetics, to development and physiology of stomata. The question of 'how relevant is screening for high/low WUE in crops for semi-arid regions, where drought and heat co-occur' is discussed.

Grapevine under deficit irrigation: hints from physiological and molecular data

BACKGROUND

A large proportion of vineyards are located in regions with seasonal drought (e.g. Mediterranean-type climates) where soil and atmospheric water deficits, together with high temperatures, exert large constraints on yield and quality. The increasing demand for vineyard irrigation requires an improvement in the efficiency of water use. Deficit irrigation has emerged as a potential strategy to allow crops to withstand mild water stress with little or no decreases of yield, and potentially a positive impact on fruit quality. Understanding the physiological and molecular bases of grapevine responses to mild to moderate water deficits is fundamental to optimize deficit irrigation management and identify the most suitable varieties to those conditions.

SCOPE

How the whole plant acclimatizes to water scarcity and how short- and long-distance chemical and hydraulic signals intervene are reviewed. Chemical compounds synthesized in drying roots are shown to act as long-distance signals inducing leaf stomatal closure and/or restricting leaf growth. This explains why some plants endure soil drying without significant changes in shoot water status. The control of plant water potential by stomatal aperture via feed-forward mechanisms is associated with 'isohydric' behaviour in contrast to 'anysohydric' behaviour in which lower plant water potentials are attained. This review discusses differences in this respect between grapevines varieties and experimental conditions. Mild water deficits also exert direct and/or indirect (via the light environment around grape clusters) effects on berry development and composition; a higher content of skin-based constituents (e.g. tannins and anthocyanins) has generally being reported. Regulation under water deficit of genes and proteins of the various metabolic pathways responsible for berry composition and therefore wine quality are reviewed.