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Gadzinski AJ, Dwyer EM, Reynolds J, Stewart B, Abarro I, Wolff EM, Ellimoottil C, Holt SK, Gore JL. Interstate Telemedicine for Urologic Cancer Care. J Urol 2024; 211:55-62. [PMID: 37831635 PMCID: PMC10842529 DOI: 10.1097/ju.0000000000003749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 09/29/2023] [Indexed: 10/15/2023]
Abstract
PURPOSE US states eased licensing restrictions on telemedicine during the COVID-19 pandemic, allowing interstate use. As waivers expire, optimal uses of telemedicine must be assessed to inform policy, legislation, and clinical care. We assessed whether telemedicine visits provided the same patient experience as in-person visits, stratified by in- vs out-of-state residence, and examined the financial burden. MATERIALS AND METHODS Patients seen in person and via telemedicine for urologic cancer care at a major regional cancer center received a survey after their first appointment (August 2019-June 2022) on satisfaction with care, perceptions of communication during their visit, travel time, travel costs, and days of work missed. RESULTS Surveys were completed for 1058 patient visits (N = 178 in-person, N = 880 telemedicine). Satisfaction rates were high for all visit types, both interstate and in-state care (mean score 60.1-60.8 [maximum 63], P > .05). More patients convening interstate telemedicine would repeat that modality (71%) than interstate in-person care (61%) or in-state telemedicine (57%). Patients receiving interstate care had significantly higher travel costs (median estimated visit costs $200, IQR $0-$800 vs median $0, IQR $0-$20 for in-state care, P < .001); 55% of patients receiving interstate in-person care required plane travel and 60% required a hotel stay. CONCLUSIONS Telemedicine appointments may increase access for rural-residing patients with cancer. Satisfaction outcomes among patients with urologic cancer receiving interstate care were similar to those of patients cared for in state; costs were markedly lower. Extending interstate exemptions beyond COVID-19 licensing waivers would permit continued delivery of high-quality urologic cancer care to rural-residing patients.
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Affiliation(s)
| | - Erin M Dwyer
- Department of Urology, University of Washington, Seattle, Washington
| | - Jason Reynolds
- Department of Urology, University of Washington, Seattle, Washington
| | - Blair Stewart
- Department of Urology, University of Washington, Seattle, Washington
| | - Isabelle Abarro
- Department of Urology, University of Washington, Seattle, Washington
| | - Erika M Wolff
- Department of Urology, University of Washington, Seattle, Washington
| | - Chad Ellimoottil
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Sarah K Holt
- Department of Urology, University of Washington, Seattle, Washington
| | - John L Gore
- Department of Urology, University of Washington, Seattle, Washington
- Department of Surgery, University of Washington, Seattle, Washington
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
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Dwyer ER, Holt SK, Wolff EM, Stewart B, Katz R, Reynolds J, Gadzinski AJ, Gore JL. Patient-centered outcomes of telehealth for the care of rural-residing patients with urologic cancer. Cancer 2023; 129:2887-2892. [PMID: 37221660 DOI: 10.1002/cncr.34848] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/27/2023] [Accepted: 04/14/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Patients residing in rural areas with urologic cancers confront significant obstacles in obtaining oncologic care. In the Pacific Northwest, a sizeable portion of the population lives in a rural county. Telehealth offers a potential access solution. METHODS Patients receiving urologic care through telehealth or an in-person appointment at the Fred Hutchinson Cancer Center in Seattle, Washington, were surveyed to assess appointment-related satisfaction and travel costs. Patients' residences were classified as rural or urban based on their self-reported ZIP code. Median patient satisfaction scores and appointment-related travel costs were compared by rural versus urban residence within telehealth and in-person appointment groups using Wilcoxon signed-rank or χ2 testing. RESULTS A total of 1091 patients seen for urologic cancer care between June 2019 and April 2022 were included, 28.7% of which resided in a rural county. Patients were mostly non-Hispanic White (75%) and covered by Medicare (58%). Among rural-residing patients, telehealth and in-person appointment groups had the same median satisfaction score (61; interquartile ratio, 58, 63). More rural-residing than urban-residing patients in the telehealth appointment groups strongly agreed that "Considering the cost and time commitment of my appointment, I would choose to meet with my provider in this setting in the future" (67% vs. 58%, p = .03). Rural-residing patients with in-person appointments carried a higher financial burden than those with telehealth appointments (medians, $80 vs. $0; p <.001). CONCLUSIONS Appointment-related costs are high among rural-residing patients traveling for urologic oncologic care. Telehealth provides an affordable solution that does not compromise patient satisfaction.
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Affiliation(s)
- Erin R Dwyer
- Department of Urology, University of Washington, Seattle, Washington, USA
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Sarah K Holt
- Department of Urology, University of Washington, Seattle, Washington, USA
| | - Erika M Wolff
- Department of Urology, University of Washington, Seattle, Washington, USA
| | - Blair Stewart
- Department of Urology, University of Washington, Seattle, Washington, USA
| | - Ronit Katz
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - Jason Reynolds
- Department of Urology, University of Washington, Seattle, Washington, USA
| | | | - John L Gore
- Department of Urology, University of Washington, Seattle, Washington, USA
- Fred Hutchinson Cancer Center, Seattle, Washington, USA
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Chang EK, Gadzinski AJ, Nyame YA. Blood and urine biomarkers in prostate cancer: Are we ready for reflex testing in men with an elevated prostate-specific antigen? Asian J Urol 2021; 8:343-353. [PMID: 34765442 PMCID: PMC8566358 DOI: 10.1016/j.ajur.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/17/2021] [Accepted: 05/26/2021] [Indexed: 10/28/2022] Open
Abstract
Objective There is no consensus on the role of biomarkers in determining the utility of prostate biopsy in men with elevated prostate-specific antigen (PSA). There are numerous biomarkers such as prostate health index, 4Kscore, prostate cancer antigen 3, ExoDX, SelectMDx, and Mi-Prostate Score that may be useful in this decision-making process. However, it is unclear whether any of these tests are accurate and cost-effective enough to warrant being a widespread reflex test following an elevated PSA. Our goal was to report on the clinical utility of these blood and urine biomarkers in prostate cancer screening. Methods We performed a systematic review of studies published between January 2000 and October 2020 to report the available parameters and cost-effectiveness of the aforementioned diagnostic tests. We focus on the negative predictive value, the area under the curve, and the decision curve analysis in comparing reflexive tests due to their relevance in evaluating diagnostic screening tests. Results Overall, the biomarkers are roughly equivalent in predictive accuracy. Each test has additional clinical utility to the current diagnostic standard of care, but the added benefit is not substantial to justify using the test reflexively after an elevated PSA. Conclusions Our findings suggest these biomarkers should not be used in binary fashion and should be understood in the context of pre-existing risk predictors, patient's ethnicity, cost of the test, patient life-expectancy, and patient goals. There are more recent diagnostic tools such as multi-parametric magnetic resonance imaging, polygenic single-nucleotide panels, IsoPSA, and miR Sentinel tests that are promising in the realm of prostate cancer screening and need to be investigated further to be considered a consensus reflexive test in the setting of prostate cancer screening.
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Affiliation(s)
- Edward K Chang
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA
| | - Adam J Gadzinski
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA
| | - Yaw A Nyame
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA.,Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Patel M, Gadzinski AJ, Bell AM, Watts K, Steppe E, Odisho AY, Yang CC, Ellimoottil C. Interprofessional Consultations (eConsults) in Urology. Urol Pract 2021; 8:321-327. [PMID: 33928183 PMCID: PMC8078010 DOI: 10.1097/upj.0000000000000209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION An interprofessional consultation (eConsult) is an asynchronous form of telehealth whereby a primary care provider requests electronic consultation with a specialist in place of an in-person consultation. While eConsults have been successfully implemented in many medical specialties, their use in the practice of urology is relatively unknown. METHODS We included data from four academic institutions: University of Michigan, University of California -San Francisco, University of Washington, and Montefiore Medical Center. We included every urological eConsult performed at each institution from the launch of their respective programs through August 2019. We considered an eConsult "converted" when the participating urologist recommended a full in-person evaluation. We report eConsult conversion rate, response time, completion time, and diagnosis categories. RESULTS A total of 462 urological eConsults were requested. Of these, 36% were converted to a traditional in-person visit. Among resolved eConsults, with data on provider response time available (n=119),53.8% of eConsults were addressed in less than 1 day; 28.6% in 1 day; 8.4% in 2 days; 3.4% in 3 days; 3.4% in 4 days; 1.7% in 5 days; and 0.8% in ≥6 days. Among resolved eConsults, with data on provider completion time available (n=283), 50.2% were completed in 1-10 minutes; 46.7% in 11-20 minutes; 2.8% in 21-30 minutes; and less than 1% in ≥31 minutes. DISCUSSION Our study suggests that eConsults are an effective avenue for urologists to provide recommendations for many common non-surgical urological conditions and thus avoid a traditional in-person for low-complexity situations. Further investigation into the impact of eConsults on healthcare costs and access to urological care are necessary.
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Affiliation(s)
- Milan Patel
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Urology, University of Michigan, Ann Arbor
| | | | | | - Kara Watts
- Department of Urology, Montefiore Medical Center, New York
| | - Emma Steppe
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Anobel Y. Odisho
- Department of Urology, University of California, San Francisco
- Center for Digital Health Innovation, University of California, San Francisco
| | - Claire C. Yang
- Department of Urology, University of Washington, Seattle
| | - Chad Ellimoottil
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Urology, University of Michigan, Ann Arbor
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Gadzinski AJ, Andino JJ, Odisho AY, Watts KL, Gore JL, Ellimoottil C. Telemedicine and eConsults for Hospitalized Patients During COVID-19. Urology 2020; 141:12-14. [PMID: 32330533 PMCID: PMC7172813 DOI: 10.1016/j.urology.2020.04.061] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Indexed: 02/07/2023]
Affiliation(s)
| | - Juan J Andino
- Department of Urology, University of Michigan, Ann Arbor, MI
| | - Anobel Y Odisho
- Department of Urology and Center for Digital Health Innovation, University of California, San Francisco, CA
| | - Kara L Watts
- Department of Urology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - John L Gore
- Department of Urology, University of Washington, Seattle, WA
| | - Chad Ellimoottil
- Department of Urology, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
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Gadzinski AJ, Psutka SP. Risk stratification metrics for bladder cancer: Comprehensive Geriatric Assessments. Urol Oncol 2020; 38:725-733. [PMID: 32037198 DOI: 10.1016/j.urolonc.2020.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 12/27/2019] [Accepted: 01/08/2020] [Indexed: 12/26/2022]
Abstract
Despite advances in surgical technique and perioperative care pathways, complication rates following radical cystectomy for bladder cancer remain high and perioperative outcomes for elderly patients are suboptimal. Furthermore, subjective risk assessments of patients with bladder cancer, with a high prevalence of complex comorbidity burden and risk of frailty, may result in undertreatment of patients assumed to be poor operative candidates. A critical component of preoperative patient counseling and treatment selection is accurate and objective preoperative risk appraisal. Comprehensive Geriatric Assessments are multi-domain evaluations of the medical, functional, and psychosocial aspects of health designed specifically for use in elderly patients with the objective of identifying vulnerabilities that may be targeted with interventions for improvement. While currently recommended by multiple guideline bodies for use in the preoperative evaluation of elderly patients with bladder cancer there is a paucity of data describing their use in contemporary clinical practice. Herein, then, we will describe the components of a Comprehensive Geriatric Assessments and propose strategies for their integration into the preoperative surgical workflow.
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Affiliation(s)
| | - Sarah P Psutka
- Department of Urology, University of Washington, Seattle, WA.
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Xu MJ, Kornberg Z, Gadzinski AJ, Diao D, Cowan JE, Wu SY, Boreta L, Spratt DE, Behr SC, Nguyen HG, Cooperberg MR, Davicioni E, Roach M, Hope TA, Carroll PR, Feng FY. Genomic Risk Predicts Molecular Imaging-detected Metastatic Nodal Disease in Prostate Cancer. Eur Urol Oncol 2019; 2:685-690. [PMID: 31411984 DOI: 10.1016/j.euo.2018.11.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 11/05/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Decipher genomic classifier (GC) is increasingly being used to determine metastasis risk in men with localized prostate cancer (PCa). Whether GCs predict for the presence of occult metastatic disease at presentation or subsequent metastatic progression is unknown. OBJECTIVE To determine if GC scores predict extraprostatic 68Ga prostate-specific membrane antigen (68Ga-PSMA-11) positron emission tomography (PET) positivity at presentation. DESIGN, SETTING, AND PARTICIPANTS Between December 2015 and September 2018, 91 PCa patients with both GC scores and pretreatment 68Ga-PSMA-11 PET scans were identified. Risk stratification was performed using the National Comprehensive Cancer Network (NCCN), Cancer of the Prostate Risk Assessment (CAPRA), and GC scores. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Logistic regression was used to identify factors correlated with PSMA-positive disease. RESULTS AND LIMITATIONS The NCCN criteria identified 23 (25.3%) and 68 patients (74.7%) as intermediate and high risk, while CAPRA scores revealed 28 (30.8%) and 63 (69.2%) as low/intermediate and high risk, respectively. By contrast, only 45 patients (49.4%) had high-risk GC scores. PSMA-avid pelvic nodal involvement was identified in 27 patients (29.7%). Higher GC score was significantly associated with pelvic nodal involvement (odds ratio [OR] 1.38 per 0.1 units; p=0.009) and any PSMA-avid nodal involvement (pelvic or distant; OR 1.40 per 0.1 units; p=0.007). However, higher GC score was not significantly associated with PSMA-avid osseous metastases (OR 1.11 per 0.1 units; p=0.50). Limitations include selection bias for patients able to receive both tests and the sample size. CONCLUSIONS Each 0.1-unit increase in GC score was associated with an approximate 40% increase in the odds of PSMA-avid lymph node involvement. These data suggest that patients with GC high risk might benefit from more nodal imaging and treatment intensification, potentially via pelvic nodal dissection, pelvic nodal irradiation, and/or the addition of chemohormonal agents. PATIENT SUMMARY Patients with higher genomic classifier scores were found to have more metastatic lymph node involvement on prostate-specific membrane antigen imaging.
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Affiliation(s)
- Melody J Xu
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Zachary Kornberg
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Adam J Gadzinski
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Dongmei Diao
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA; Department of Surgical Oncology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Janet E Cowan
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Susan Y Wu
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Lauren Boreta
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Daniel E Spratt
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA
| | - Spencer C Behr
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Hao G Nguyen
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Matthew R Cooperberg
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | | | - Mack Roach
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Peter R Carroll
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Felix Y Feng
- Department of Radiation Oncology, University of California San Francisco, San Francisco, CA, USA; Department of Urology, University of California San Francisco, San Francisco, CA, USA.
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Sanford T, Gadzinski AJ, Gaither T, Osterberg EC, Murphy GP, Carroll PR, Breyer BN. Effect of Oscillation on Perineal Pressure in Cyclists: Implications for Micro-Trauma. Sex Med 2018; 6:239-247. [PMID: 29936216 PMCID: PMC6085221 DOI: 10.1016/j.esxm.2018.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/02/2018] [Accepted: 05/14/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Genital numbness and erectile dysfunction in cyclists may result from repeated perineal impacts on the bicycle saddle (micro-trauma) that occur during routine cycling. AIM To evaluate the relationship between oscillation forces and perineal pressures among cyclists in a simulated laboratory setting. METHODS Participants were fit to a study bicycle to ensure all cyclists had the same torso angle (60 ± 1 degree) and maximum knee angle (150 ± 1 degree). A lever system was used to generate oscillation events of 3 progressively increasing magnitudes. Perineal pressure was continuously measured using a pressure sensor on the bicycle saddle. This process was carried out in each of the following conditions: (1) stationary (not pedaling) with the standard seatpost, (2) pedaling with standard seatpost, (3) stationary with seatpost shock absorber, and (4) pedaling with seatpost shock absorber. OUTCOMES We compared perineal pressure changes during oscillation events in the stationary and pedaling states, with and without the seatpost shock absorber. RESULTS A total of 39 individuals were recruited (29 men and 10 women). As the amount of oscillation increased from an average of 0.7g (acceleration due to Earth's gravity) to 1.3g, the perineal pressure increased from 10.3% over baseline to 19.4% over baseline. There was a strong linear relationship between the amount of oscillation and increase in pressure (r2 = 0.8, P < .001). A seatpost shock absorber decreased the impact of oscillation by 53% in the stationary condition. Men and women absorbed the majority of shock in areas corresponding to pelvic bony landmarks. CONCLUSION This study represents one of the first characterizations of cycling-associated perineal micro-trauma in a laboratory setting. We found a strong linear relationship between oscillation magnitude and perineal pressure during cycling, which was mitigated by a seatpost shock absorber. The use of shock absorption in bicycle design may reduce perineal micro-trauma and potentially improve cycling-associated perineal numbness and erectile dysfunction. Sanford T, Gadzinski AJ, Gaither T, et al. Effect of Oscillation on Perineal Pressure in Cyclists: Implications for Micro-Trauma. Sex Med 2018;6:239-247.
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Affiliation(s)
- Thomas Sanford
- Department of Urology, University of California San Francisco, San Francisco, CA, USA.
| | - Adam J Gadzinski
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Thomas Gaither
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - E Charles Osterberg
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Greg P Murphy
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Peter R Carroll
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
| | - Benjamin N Breyer
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
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Gadzinski AJ, Greene KL, Carroll P, Ryan CJ, Feng FY, Hope T. Detection of prostate cancer lesions using Gallium-68 PSMA-11 PET in men with biochemical recurrence following radical prostatectomy. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.6_suppl.236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
236 Background: Conventional imaging techniques infrequently detect the site of prostate cancer disease in men with biochemical recurrence following radical prostatectomy (RP). We examine the use of Gallium-68 Prostate-Specific Membrane Antigen (PSMA) positron emission tomography (PET) to determine the site of disease recurrence in these men. Methods: We retrospectively reviewed men with persistently detectable prostate specific antigen (PSA) and those with formal biochemical recurrence (PSA ≥ 0.2 ng/mL) following RP who underwent PSMA PET scan under our institution's prospective trials (NCT02918357 & NCT02611882). We assessed the location of detected recurrences, and examined the distribution of recurrence location (prostate bed, pelvic lymph nodes (LN), and extra-pelvic disease) according to PSA at time of PET scan. Results: One hundred and fifty-eight men underwent PSMA PET after RP, 46% of men had previously undergone either adjuvant or salvage radiation therapy. Eleven men (7%) had the scan for persistently detectable PSA < 0.2 and 93% of men had biochemical recurrence. At time of RP, 66% of men had ≥pT3a disease, 40% had positive surgical margins, and 18% had positive lymph nodes. Gleason grade at RP was ≤3+3 in 5% of men, 3+4 in 27%, 4+3 in 32% and ≥4+4 in 36%. Overall, 77% of men had a lesion detectable on PSMA PET. Men with higher PSA at time of scan had a higher prevalence of lesions, with all men PSA > 6.0 having at least one lesion on PSMA PET (Table). Overall, we found extra-pelvic lesions in 44% of all men, and 58% of men with PSA ≥ 1.0. These are areas not typically covered by salvage radiation fields. Conclusions: PSMA PET detects lesions in a high proportion of men with biochemical recurrence following RP, with many lesions outside of the pelvis. This may facilitate more precise targeting of treatment areas for these patients. Clinical trial information: NCT02918357. Clinical trial information: NCT02611882. [Table: see text]
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Affiliation(s)
| | - Kirsten L Greene
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | - Peter Carroll
- University of California San Francisco, San Francisco, CA
| | - Charles J. Ryan
- UC San Francisco Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
| | - Felix Y Feng
- University of California San Francisco, San Francisco, CA
| | - Tom Hope
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA
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Abstract
Diagnostic biomarkers derived from blood, urine, or prostate tissue provide additional information beyond clinical calculators to determine the risk of detecting high-grade prostate cancer. Once diagnosed, multiple markers leverage prostate cancer biopsy tissue to prognosticate clinical outcomes, including adverse pathology at radical prostatectomy, disease recurrence, and prostate cancer mortality; however the clinical utility of some outcomes to patient decision making is unclear. Markers using tissue from radical prostatectomy specimens provide additional information about the risk of biochemical recurrence, development of metastatic disease, and subsequent mortality beyond existing multivariable clinical calculators (the use of a marker to simply sub-stratify risk groups such as the NCCN groups is of minimal value). No biomarkers currently available for prostate cancer have been prospectively validated to be predict an improved clinical outcome for a specific therapy based on the test result; however, further research and development of these tests may produce a truly predictive biomarker for prostate cancer treatment.
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Affiliation(s)
- Adam J Gadzinski
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | - Matthew R Cooperberg
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA.
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Ambani SN, Morgan TM, Montgomery JS, Gadzinski AJ, Jacobs BL, Hawken S, Krishnan N, Caoili EM, Ellis JH, Kunju LP, Hafez KS, Miller DC, Palapattu GS, Weizer AZ, Wolf JS. Predictors of Delayed Intervention for Patients on Active Surveillance for Small Renal Masses: Does Renal Mass Biopsy Influence Our Decision? Urology 2016; 98:88-96. [PMID: 27450936 DOI: 10.1016/j.urology.2016.04.067] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/27/2016] [Accepted: 04/28/2016] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To review our clinical T1a renal mass active surveillance (AS) cohort to determine whether renal mass biopsy was associated with maintenance of AS. MATERIALS AND METHODS From our prospectively maintained database we identified patients starting AS from June 2009 to December 2011 who had at least 5 months of radiologic follow-up, unless limited by unexpected death or delayed intervention. The primary outcome was delayed intervention. Clinical, radiologic, and pathologic variables were compared. We constructed Kaplan-Meier survival curves for maintenance of AS. Cox multivariable regression analysis was performed to assess predictors of delayed intervention. RESULTS We identified 118 patients who met criteria for inclusion with a median radiologic follow-up of 29.5 months. The delayed intervention group had greater initial mass size and faster growth rate compared to those who continued AS. Rate of renal mass biopsy was similar between the 2 groups. In the multivariable analysis, size >2 cm (hazard ratio [HR] 3.65, 95% confidence interval [CI] 1.28-10.38, P = .015), growth rate (continuous by mm/year: HR 1.26, 95% CI 1.12-1.41, P < .001), but not renal biopsy (HR 1.52, 95% CI 0.70-3.30, P = .29), were associated with increased risk of delayed intervention. Time-to-event curves also showed that size was closely associated with delayed intervention whereas renal mass biopsy was not. CONCLUSION At our institution, growth rate and initial tumor size appear to be more influential than renal mass biopsy results in determining delayed intervention after a period of AS. Further analysis is required to determine the role of renal biopsy in the management of patients being considered for AS.
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Affiliation(s)
- Sapan N Ambani
- Department of Urology, University of Michigan Health System, Ann Arbor, MI.
| | - Todd M Morgan
- Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | | | - Adam J Gadzinski
- Department of Urology, University of California-San Francisco, San Francisco, CA
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Scott Hawken
- University of Michigan Medical School, Ann Arbor, MI
| | | | - Elaine M Caoili
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI
| | - James H Ellis
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI
| | - Lakshmi P Kunju
- Department of Pathology, University of Michigan Health System, Ann Arbor, MI
| | - Khaled S Hafez
- Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - David C Miller
- Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Ganesh S Palapattu
- Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Alon Z Weizer
- Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - J Stuart Wolf
- Department of Urology, University of Michigan Health System, Ann Arbor, MI
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Gadzinski AJ, Dimick JB, Ye Z, Zeller JL, Miller DC. Transfer rates and use of post-acute care after surgery at critical access vs non-critical access hospitals. JAMA Surg 2014; 149:671-7. [PMID: 24827561 DOI: 10.1001/jamasurg.2013.5694] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE There is growing interest in the use of health care resources by critical access hospitals (CAHs), key providers of medical care for many rural populations. OBJECTIVE To evaluate discharge practice patterns and use of post-acute care after surgical admissions at CAHs. DESIGN, SETTING, AND PARTICIPANTS We used data from the Nationwide Inpatient Sample (2005-2009) and American Hospital Association to perform a retrospective cohort study of patients undergoing common inpatient surgical procedures at CAHs or non-CAHs. EXPOSURES The CAH status of the admitting hospital. MAIN OUTCOMES AND MEASURES Hospital transfer, discharge with post-acute care, or routine discharge. RESULTS Among the 1283 CAHs and 3612 non-CAHs included in the American Hospital Association annual survey, 34.8% and 36.4%, respectively, reported data to the Nationwide Inpatient Sample. For each of 6 common inpatient surgical procedures, a greater proportion of patients from CAHs were transferred to another hospital (P < .01); however, patients discharged from CAHs were less likely to receive post-acute care for all but 1 of the procedures examined (P < .01, except transurethral resection of prostate, P = .76). After adjustment for patient and hospital factors, the higher likelihood of transfer by CAHs vs non-CAHs persisted for 3 procedures: hip replacement (odds ratio, 1.90; 95% CI, 1.01-3.57), colorectal cancer resection (3.37; 2.23-5.09), and cholecystectomy (1.67; 1.27-2.19) (P < .05 for each), but differences in the use of post-acute care did not. In subset analyses, Medicare beneficiaries treated in CAHs were less likely to be discharged with post-acute care after hip fracture repair (odds ratio, 0.65; 95% CI, 0.47-0.89) and hip replacement (0.70; 95% CI, 0.51-0.96). CONCLUSIONS AND RELEVANCE Hospital transfers occur more often after surgical admissions at CAHs. However, the proportion of patients at CAHs using post-acute care is equal to or lower than that of patients treated in non-CAHs. These results will affect the ongoing debate concerning CAH payment policy and its implications for health care delivery in rural communities.
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Affiliation(s)
- Adam J Gadzinski
- Department of Urology, University of Michigan Health System, Ann Arbor
| | - Justin B Dimick
- Department of Surgery, University of Michigan Health System, Ann Arbor3Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan Health System, Ann Arbor
| | - Zaojun Ye
- Department of Urology, University of Michigan Health System, Ann Arbor
| | - John L Zeller
- Department of Orthopedic Surgery, University of Michigan Health System, Ann Arbor5Department of Emergency Medicine, University of Michigan Health System, Ann Arbor6Department of Medical Education, University of Michigan Health System, Ann Arbor
| | - David C Miller
- Department of Urology, University of Michigan Health System, Ann Arbor3Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, University of Michigan Health System, Ann Arbor
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Gadzinski AJ, Dimick JB, Ye Z, Miller DC. Utilization and outcomes of inpatient surgical care at critical access hospitals in the United States. JAMA Surg 2013; 148:589-96. [PMID: 23636896 DOI: 10.1001/jamasurg.2013.1224] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE There is a growing interest in the quality and cost of care provided at Critical Access Hospitals (CAHs), a predominant source of care for many rural populations in the United States. OBJECTIVE To evaluate utilization, outcomes, and costs of inpatient surgery performed at CAHs. DESIGN, SETTING, AND PATIENTS A retrospective cohort study of patients undergoing inpatient surgery from 2005 through 2009 at CAHs or non-CAHs was performed using data from the Nationwide Inpatient Sample and American Hospital Association. EXPOSURE The CAH status of the admitting hospital. MAIN OUTCOMES AND MEASURES In-hospital mortality, prolonged length of stay, and total hospital costs. RESULTS Among the 1283 CAHs and 3612 non-CAHs reporting to the American Hospital Association, 34.8% and 36.4%, respectively, had at least 1 year of data in the Nationwide Inpatient Sample. General surgical, gynecologic, and orthopedic procedures composed 95.8% of inpatient cases at CAHs vs 77.3% at non-CAHs (P < .001). For 8 common procedures examined (appendectomy, cholecystectomy, colorectal cancer resection, cesarean delivery, hysterectomy, knee replacement, hip replacement, and hip fracture repair), mortality was equivalent between CAHs and non-CAHs (P > .05 for all), with the exception that Medicare beneficiaries undergoing hip fracture repair in CAHs had a higher risk of in-hospital death (adjusted odds ratio = 1.37; 95% CI, 1.01-1.87). However, despite shorter hospital stays (P ≤ .001 for 4 procedures), costs at CAHs were 9.9% to 30.1% higher (P < .001 for all 8 procedures). CONCLUSIONS AND RELEVANCE In-hospital mortality for common low-risk procedures is indistinguishable between CAHs and non-CAHs. Although our findings suggest the potential for cost savings, changes in payment policy for CAHs could diminish access to essential surgical care for rural populations.
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Affiliation(s)
- Adam J Gadzinski
- Department of Urology, University of Michigan Health System, Ann Arbor, MI 48109, USA
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Gadzinski AJ, Jacobs BL, Halverson SJ, Miller DC, Montgomery JS, Hafez KS, Wolf JS, Weizer AZ. 1306 OUTCOMES OF PATIENTS PURSUING ACTIVE SURVEILLANCE FOR A SMALL RENAL MASS. J Urol 2013. [DOI: 10.1016/j.juro.2013.02.2660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Halverson SJ, Kunju LP, Bhalla R, Gadzinski AJ, Alderman M, Miller DC, Montgomery JS, Weizer AZ, Wu A, Hafez KS, Wolf JS. Accuracy of determining small renal mass management with risk stratified biopsies: confirmation by final pathology. J Urol 2012; 189:441-6. [PMID: 23253955 DOI: 10.1016/j.juro.2012.09.032] [Citation(s) in RCA: 158] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 08/23/2012] [Indexed: 01/28/2023]
Abstract
PURPOSE We assess the accuracy of a biopsy directed treatment algorithm in correctly assigning active surveillance vs treatment in patients with small renal masses by comparing biopsy results with final surgical pathology. MATERIALS AND METHODS From 1999 to 2011, 151 patients with small renal masses 4 cm or smaller underwent biopsy and subsequent surgical excision. Biopsy revealed cell type and grade in 133 patients, allowing the hypothetical assignment of surveillance vs treatment using an algorithm incorporating small renal mass size and histological risk group. We compared the biopsy directed management recommendation with the ideal management as defined by final surgical pathology. RESULTS Biopsy called for surveillance of 36 small renal masses and treatment of 97 small renal masses. Final pathology showed 11 patients initially assigned to surveillance should have been assigned to treatment (8.3% of all patients, 31% of those recommended for surveillance), whereas no patients moved from treatment to surveillance. Agreement between biopsy and final pathology was 92%. Using management based on final pathology as the reference standard, biopsy had a negative predictive value of 0.69 and positive predictive value 1.0 for determining management. Of the 11 misclassified cases, 7 had a biopsy indicating grade 1 clear cell renal cancer which was upgraded to grade 2 (5) or grade 3 (2). After modifying the histological risk group assignment to account for undergrading of clear cell renal cancer, agreement improved to 97%, with a negative predictive value of 0.86 and a positive predictive value of 1.0. CONCLUSIONS Our results suggest that compared to final pathology, biopsy of small renal masses accurately informs an algorithm incorporating size and histological risk group that directs the management of small renal masses.
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Gadzinski AJ, Dimick JB, Ye Z, Miller DC. Inpatient urological surgery at critical access hospitals in the United States. J Urol 2012; 189:1475-80. [PMID: 23041344 DOI: 10.1016/j.juro.2012.09.122] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 09/26/2012] [Indexed: 11/17/2022]
Abstract
PURPOSE To better understand urological care delivery in rural communities, we evaluated the utilization, outcomes and costs of inpatient urological surgery at critical access hospitals. MATERIALS AND METHODS Using data from the AHA (American Hospital Association) and NIS (Nationwide Inpatient Sample), we identified all urological surgical admissions to critical and noncritical access hospitals from 2005 through 2009. We compared the distribution of urological procedures, hospital mortality, length of stay and costs for patients undergoing common urological operations at critical vs noncritical access hospitals. RESULTS Of the 1,292 critical and 3,760 noncritical access hospitals reporting to the AHA 450 (35%) and 1,372 (36%), respectively, had at least 1 year of data available in the NIS. We identified 333,925 urological surgical admissions, including 2,286 (0.7%) to critical access hospitals. Overall, at least 1 inpatient urological operation was performed at only 45% of critical access hospitals vs 91% of noncritical access hospitals (p <0.001). The distribution of urological surgeries differed between critical and noncritical access hospitals (p <0.001) with a greater prevalence of operations for benign indications at critical access hospitals. For 6 common inpatient urological surgeries we found no meaningful difference in in-hospital mortality and prolonged length of stay between patients treated at critical vs noncritical access hospitals. However, costs at critical access hospitals were universally higher. CONCLUSIONS Inpatient urological surgery is performed at only a few critical access hospitals. While in-hospital mortality and length of stay are largely indistinguishable between critical and noncritical access hospitals, the higher costs at critical access hospitals may pose a challenge to improving rural access to urological care.
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Affiliation(s)
- Adam J Gadzinski
- Departments of Urology and Surgery (JBD), University of Michigan Health System, Ann Arbor, Michigan 48109, USA
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Gadzinski AJ, Roberts WW, Faerber GJ, Wolf JS. Authors' Response to Letter to the Editor. J Endourol 2012. [DOI: 10.1089/end.2012.1527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Gary J. Faerber
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - J. Stuart Wolf
- Department of Urology, University of Michigan, Ann Arbor, Michigan
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Gadzinski AJ, Roberts WW, Faerber GJ, Wolf JS. Long-term Outcomes of Immediate Versus Delayed Nephroureterectomy for Upper Tract Urothelial Carcinoma. J Endourol 2012; 26:566-73. [DOI: 10.1089/end.2011.0220] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Gary J. Faerber
- Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - J. Stuart Wolf
- Department of Urology, University of Michigan, Ann Arbor, Michigan
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Halverson SJ, Gadzinski AJ, Kunju LP, Miller DC, Montgomery JS, Weizer AZ, Wolf JS, Hafez KS. 710 ACCURACY OF DETERMINING SMALL RENAL MASS (SRM) MANAGEMENT WITH RISK-STRATIFIED BIOPSIES CONFIRMATION BY FINAL PATHOLOGY. J Urol 2012. [DOI: 10.1016/j.juro.2012.02.794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Gadzinski AJ, Roberts WW, Faerber GJ, Wolf JS. Long-term outcomes of nephroureterectomy versus endoscopic management for upper tract urothelial carcinoma. J Urol 2010; 183:2148-53. [PMID: 20399468 DOI: 10.1016/j.juro.2010.02.005] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Indexed: 01/03/2023]
Abstract
PURPOSE We compared outcomes in patients treated with nephroureterectomy vs nephron sparing endoscopic surgery for upper tract urothelial carcinoma. MATERIALS AND METHODS Patients treated at our institution for upper tract urothelial carcinoma from 1996 to 2004 were monitored for upper tract and bladder recurrence, metastasis, and cancer specific and overall survival. Outcomes were compared between treatment groups by univariate and multivariate analyses based on pertinent pathological and demographic variables. RESULTS Of 96 renal units 62 underwent immediate nephroureterectomy and 34 were managed endoscopically. Median followup in all survivors was 77 months. Overall nephroureterectomy and endoscopy complication rates were 29% and 9.3%, respectively. In patients with low grade tumors the 5-year metastasis-free survival rate after nephroureterectomy and endoscopy was 88% and 94%. The corresponding 5-year cancer specific and overall survival rates were 89% vs 100% and 72% vs 75%, respectively. Of endoscopic cases 84% had at least 1 ipsilateral recurrence. Multivariate analysis revealed that only tumor grade was significantly associated with metastasis-free survival while grade and body mass index correlated with cancer specific survival, and Charlson Comorbidity index and grade impacted overall survival. Treatment group was not associated with survival outcome. CONCLUSIONS When technically feasible and in select patients, endoscopic management provides cancer related and overall survival equivalent to that of nephroureterectomy in patients with low grade upper tract urothelial carcinoma at the cost of frequent re-treatments in many patients. Nephroureterectomy is standard treatment for high grade cancer when there is a normal contralateral kidney but endoscopy should be considered when there are imperative indications for nephron sparing.
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Affiliation(s)
- Adam J Gadzinski
- Department of Urology, University of Michigan Health System, Ann Arbor, Michigan 48109-0330, USA
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