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Triner D, Daignault-Newton S, Singhal U, Sessine M, Dess RT, Caram MEV, Borza T, Ginsburg KB, Lane BR, Morgan TM. Variation in management of lymph node positive prostate cancer after radical prostatectomy within a statewide quality improvement consortium. Urol Oncol 2024:S1078-1439(24)00398-3. [PMID: 38570271 DOI: 10.1016/j.urolonc.2024.03.015] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/11/2024] [Accepted: 03/16/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Patients with lymph node positive (pN+) disease found at the time of radical prostatectomy with pelvic lymphadenectomy for clinically localized prostate cancer (CaP) are at high risk of disease persistence and progression. Contemporary management trends of pN+ CaP are not well described. MATERIALS AND METHODS Patients in the Michigan Urologic Surgery Improvement Collaborative (MUSIC) with clinically localized prostate cancer who underwent radical prostatectomy between 2012 and 2023 with cN0/pN+ disease were identified. The primary outcome was to evaluate patient and practice-level factors associated with time to secondary post-RP treatment. Secondary outcomes included practice-level variation in management of pN+ CaP and rates of secondary treatment modality. To assess factors associated with secondary treatment, a Cox proportional hazards model of a 60-day landmark analysis was performed. RESULTS We identified 666 patients with pN+ disease. Overall, 66% underwent secondary treatment within 12 months post-RP. About 19% of patients with detectable post-RP PSA did not receive treatment. Of patients receiving secondary treatment after 60-days post-RP, 34% received androgen deprivation therapy (ADT) alone, 27% received radiation (RT) alone, 36% received combination, and 4% received other systemic therapies. In the multivariable model, pathologic grade group (GG)3 (HR 1.5; 95%CI: 1.05-2.14), GG4-5 (HR 1.65; 95%CI: 1.16-2.34), positive margins (HR 1.46; 95%CI: 1.13-1.88), and detectable postoperative PSA ≥0.1 ng/ml (HR 3.46; 95%CI: 2.61-4.59) were significantly associated with secondary post-RP treatment. There was wide variation in adjusted practice-level 12-month secondary treatment utilization (28%-79%). CONCLUSIONS The majority pN+ patients receive treatment within 12 months post-RP which was associated with high-risk pathological features and post-RP PSA. Variation in management of pN+ disease highlights the uncertainty regarding the optimal management. Understanding which patients will benefit from secondary treatment, and which type, will be critical to minimize variation in care.
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Affiliation(s)
- Daniel Triner
- Department of Urology, Michigan Medicine, Ann Arbor, MI.
| | | | - Udit Singhal
- Department of Urology, Michigan Medicine, Ann Arbor, MI; Department of Urology, Mayo Clinic, Rochester, MN
| | - Michael Sessine
- Department of Urology, Wayne State University School of Medicine, Detroit, MI
| | - Robert T Dess
- Department of Radiation Oncology, Michigan Medicine, Ann Arbor, MI
| | - Megan E V Caram
- Division of Hematology/Oncology, Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI
| | - Tudor Borza
- Department of Urology, Michigan Medicine, Ann Arbor, MI
| | - Kevin B Ginsburg
- Department of Urology, Wayne State University School of Medicine, Detroit, MI
| | - Brian R Lane
- Division of Urology, Corewell Health Hospital System, Grand Rapids, MI
| | - Todd M Morgan
- Department of Urology, Michigan Medicine, Ann Arbor, MI
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Sakai A, Borza T, Antar A, Richmond E, Allen GO, Knoedler M, Manakas C, Huang W, Gralnek D, Grimes MD. Incidental Prostate Cancer Diagnosis Is Common After Holmium Laser Enucleation of the Prostate. Urology 2024; 183:170-175. [PMID: 38043905 PMCID: PMC10872358 DOI: 10.1016/j.urology.2023.11.014] [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: 08/19/2023] [Revised: 10/30/2023] [Accepted: 11/22/2023] [Indexed: 12/05/2023]
Abstract
OBJECTIVE To determine the incidence of incidental prostate cancer detection (iPCa) after holmium laser enucleation of the prostate (HoLEP). The published rate of iPCa after HoLEP is widely variable from 7% to 23% and we aim to define preoperative risk factors for iPCa to inform risk-adjusted preoperative evaluation for PCa. METHODS Consecutive patients undergoing HoLEP from 2018 to 2022 were included and comprehensive clinical data abstracted from a prospectively maintained database. iPCa was defined as a diagnosis of PCa on pathologic examination of the HoLEP specimen. Patients with and without iPCa were compared with respect to preoperative clinical variables. RESULTS Of 913 HoLEP patients, 183 (20%) were diagnosed with iPCa. Most patients (95%) had a preoperative prostate-specific antigen (PSA), 9% had negative MRI, and 30% had negative prostate biopsy. On multivariable analysis, PSA density (OR 1.06; 95% CI 1.03, 1.10; P < .001), preoperative biopsy status (OR 0.47, CI 0.30, 0.75; P = .002), and current 5-alpha reductase inhibitor use (OR 0.64, CI 0.43, 0.97; P = .034), were associated with iPCa diagnosis. CONCLUSION In a significantly prescreened population, we identified a 20% rate of iPCa after HoLEP. Preoperative characteristics associated with iPCa diagnosis included increasing age, increasing PSA density, and current 5-alpha reductase inhibitor use. However, these factors alone may be of limited clinical utility to prospectively identify patients at high risk of iPCa diagnosis. We suggest and advocate for development of a standardized, risk-adapted evaluation focused on expanded use of imaging and selective biopsy to prioritize identification of clinically significant PCa prior to nononcologic surgery.
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Affiliation(s)
- Akihisa Sakai
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Tudor Borza
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Ali Antar
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Ethan Richmond
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Glenn O Allen
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Margaret Knoedler
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Christopher Manakas
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Wei Huang
- Department of Pathology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Daniel Gralnek
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI
| | - Matthew D Grimes
- Department of Urology, School of Medicine and Public Health, University of Wisconsin, Madison, WI.
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Penn T, Borza T, Liou JI, Jason Abel E, Shapiro DD, Jarrard DF, Ricke WA, Richards KA. Impact of Agent Orange Exposure on Non-muscle Invasive Bladder Cancer Outcomes. Urology 2023; 182:175-180. [PMID: 37730166 DOI: 10.1016/j.urology.2023.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE To explore the effect of Agent Orange (AO) exposure on bladder cancer (BCa) outcomes in patients receiving Bacillus Calmette-Guérin (BCG) for non-muscle invasive BCa (NMIBC). METHODS We retrospectively examined the association between AO exposure in patients with NMIBC in national veterans affairs databases who were being treated with BCG. Patients were diagnosed with NMIBC from 2000 to 2010 with follow-up through 2018. Clinical, pathological, and demographic variables were compared by AO exposure. Associations of AO exposure with recurrence, progression, and cancer-specific survival were performed using Cox proportional hazard models after inverse propensity score weighting and competing risks adjustments. We also assessed the association of AO exposure on grade and stage via multivariable logistic regression models. RESULTS A total of 7651 patients were identified of which 753 (9.8%) were exposed to AO. The median follow-up time was 130 months. The AO-exposed patients were younger (age 61 vs 71 years, P <.001), but had similar Charlson comorbidity scores and stage/grade distribution as the non-AO exposed patients. AO exposure was not associated with higher grade or stage. In our Cox multivariable analyses, AO exposure was not associated with worse recurrence (hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.72-1.10, P = .29), progression (HR 1.08, 95% CI 0.86-1.36, P = .51), or cancer-specific survival (HR 1.31, 95% CI 0.92-1.87, P = .13). CONCLUSION AO exposure was not associated with worse oncologic outcomes in patients receiving BCG for NMIBC. While this is reassuring, additional research is needed in other patient populations and disease states to determine if the effect is consistent.
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Affiliation(s)
- Taylor Penn
- The University of Wisconsin-Madison, Department of Urology, Madison, WI
| | - Tudor Borza
- The University of Wisconsin-Madison, Department of Urology, Madison, WI
| | - Jinn-Ing Liou
- The University of Wisconsin-Madison, Department of Medicine, Madison, WI
| | - E Jason Abel
- The University of Wisconsin-Madison, Department of Urology, Madison, WI
| | - Daniel D Shapiro
- The University of Wisconsin-Madison, Department of Urology, Madison, WI; William S. Middleton Memorial Veterans Hospital, Division of Urology, Madison, WI
| | - David F Jarrard
- The University of Wisconsin-Madison, Department of Urology, Madison, WI
| | - William A Ricke
- The University of Wisconsin-Madison, Department of Urology, Madison, WI
| | - Kyle A Richards
- The University of Wisconsin-Madison, Department of Urology, Madison, WI; William S. Middleton Memorial Veterans Hospital, Division of Urology, Madison, WI.
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Nishtala MV, Karim AS, Melnick D, Delarwelle T, Lawson E, Greenberg CC, Borza T. Disposal of Unused Postoperative Opioids: A Real-World Demonstration of Surgeon-initiated Strategies Using an Activated Charcoal Bag System. Ann Surg Open 2023; 4:e313. [PMID: 37746621 PMCID: PMC10513361 DOI: 10.1097/as9.0000000000000313] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/16/2023] [Indexed: 09/26/2023] Open
Abstract
Excessive opioid prescribing following surgery creates a reservoir of unused medications available for diversion and abuse. We conducted a cohort study examining the impact of clinic-based, surgeon-initiated strategies using an activated charcoal bag (ACB) system on disposal of unused opioids. Among patients undergoing a variety of general surgery procedures, 67% of those with unused opioids disposed of them using the ACB. Our findings demonstrate practical ways to incorporate opioid disposal into surgical practice as a complement to judicious opioid prescribing.
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Affiliation(s)
| | - Aos S. Karim
- From the Department of Surgery), University of Wisconsin, Madison, WI
| | - David Melnick
- From the Department of Surgery), University of Wisconsin, Madison, WI
| | | | - Elise Lawson
- From the Department of Surgery), University of Wisconsin, Madison, WI
- Wisconsin Surgical Outcomes Research Program (WISOR), University of Wisconsin, Madison, WI
| | | | - Tudor Borza
- From the Department of Surgery), University of Wisconsin, Madison, WI
- Wisconsin Surgical Outcomes Research Program (WISOR), University of Wisconsin, Madison, WI
- Department of Urology, University of Wisconsin, Madison, WI
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Patel JS, Selvaraj V, More P, Bahmani R, Borza T, Prithiviraj B. A Plant Biostimulant from Ascophyllum nodosum Potentiates Plant Growth Promotion and Stress Protection Activity of Pseudomonas protegens CHA0. Plants (Basel) 2023; 12:1208. [PMID: 36986897 PMCID: PMC10053968 DOI: 10.3390/plants12061208] [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] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/28/2023] [Accepted: 03/06/2023] [Indexed: 06/18/2023]
Abstract
Abiotic stresses, including salinity stress, affect numerous crops, causing yield reduction, and, as a result, important economic losses. Extracts from the brown alga Ascophyllum nodosum (ANE), and compounds secreted by the Pseudomonas protegens strain, CHA0, can mitigate these effects by inducing tolerance against salt stress. However, the influence of ANE on P. protegens CHA0 secretion, and the combined effects of these two biostimulants on plant growth, are not known. Fucoidan, alginate, and mannitol are abundant components of brown algae and of ANE. Reported here are the effects of a commercial formulation of ANE, fucoidan, alginate, and mannitol, on pea (Pisum sativum), and on the plant growth-promoting activity of P. protegens CHA0. In most situations, ANE and fucoidan increased indole-3-acetic acid (IAA) and siderophore production, phosphate solubilization, and hydrogen cyanide (HCN) production by P. protegens CHA0. Colonization of pea roots by P. protegens CHA0 was found to be increased mostly by ANE and fucoidan in normal conditions and under salt stress. Applications of P. protegens CHA0 combined with ANE, or with fucoidan, alginate, and mannitol, generally augmented root and shoot growth in normal and salinity stress conditions. Real-time quantitative PCR analyses of P. protegens revealed that, in many instances, ANE and fucoidan enhanced the expression of several genes involved in chemotaxis (cheW and WspR), pyoverdine production (pvdS), and HCN production (hcnA), but gene expression patterns overlapped only occasionally those of growth-promoting parameters. Overall, the increased colonization and the enhanced activities of P. protegens CHA0 in the presence of ANE and its components mitigated salinity stress in pea. Among treatments, ANE and fucoidan were found responsible for most of the increased activities of P. protegens CHA0 and the improved plant growth.
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Murtha JA, Liu N, Birstler J, Hanlon BM, Venkatesh M, Hanrahan LP, Borza T, Kushner DM, Funk LM. Obesity and "obesity-related" cancers: are there body mass index cut-points? Int J Obes (Lond) 2022; 46:1770-1777. [PMID: 35817851 PMCID: PMC9615027 DOI: 10.1038/s41366-022-01178-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 06/15/2022] [Accepted: 06/23/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Despite compelling links between excess body weight and cancer, body mass index (BMI) cut-points, or thresholds above which cancer incidence increased, have not been identified. The objective of this study was to determine if BMI cut-points exist for 14 obesity-related cancers. SUBJECTS/METHODS In this retrospective cohort study, patients 18-75 years old were included if they had ≥2 clinical encounters with BMI measurements in the electronic health record (EHR) at a single academic medical center from 2008 to 2018. Patients who were pregnant, had a history of cancer, or had undergone bariatric surgery were excluded. Adjusted logistic regression was performed to identify cancers that were associated with increasing BMI. For those cancers, BMI cut-points were calculated using adjusted quantile regression for cancer incidence at 80% sensitivity. Logistic and quantile regression models were adjusted for age, sex, race/ethnicity, and smoking status. RESULTS A total of 7079 cancer patients (mean age 58.5 years, mean BMI 30.5 kg/m2) and 270,441 non-cancer patients (mean age 43.8 years, mean BMI 28.8 kg/m2) were included in the study. In adjusted logistic regression analyses, statistically significant associations were identified between increasing BMI and the incidence of kidney, thyroid, and uterine cancer. BMI cut-points were identified for kidney (26.3 kg/m2) and uterine (26.9 kg/m2) cancer. CONCLUSIONS BMI cut-points that accurately predicted development kidney and uterine cancer occurred in the overweight category. Analysis of multi-institutional EHR data may help determine if these relationships are generalizable to other health care settings. If they are, incorporation of BMI into the screening algorithms for these cancers may be warranted.
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Affiliation(s)
| | - Natalie Liu
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Jen Birstler
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - Bret M Hanlon
- Department of Surgery, University of Wisconsin, Madison, WI, USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, WI, USA
| | - Manasa Venkatesh
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Lawrence P Hanrahan
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Tudor Borza
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - David M Kushner
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Luke M Funk
- Department of Surgery, University of Wisconsin, Madison, WI, USA.
- Department of Surgery, William S. Middleton Memorial VA, Madison, WI, USA.
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Tilhou AS, Glass JE, Hetzel SJ, Shana OE, Borza T, Baltes A, Deyo BMF, Agarwal S, O'Rourke A, Brown RT. Association between spine injury and opioid misuse in a prospective cohort of Level I trauma patients. OTA Int 2022; 5:e205.1-6. [PMID: 36275837 PMCID: PMC9575565 DOI: 10.1097/oi9.0000000000000205] [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: 09/26/2021] [Accepted: 03/20/2022] [Indexed: 11/25/2022]
Abstract
Objective To explore patient and treatment factors explaining the association between spine injury and opioid misuse. Design Prospective cohort study. Setting Level I trauma center in a Midwestern city. Participants English speaking patients aged 18 to 75 on Trauma and Orthopedic Surgical Services receiving opioids during hospitalization and prescribed at discharge. Exposure Spine injury on the Abbreviated Injury Scale. Main outcome measures Opioid misuse was defined by using opioids: in a larger dose, more often, or longer than prescribed; via a non-prescribed route; from someone other than a prescriber; and/or use of heroin or opium. Exploratory factor groups included demographic, psychiatric, pain, and treatment factors. Multivariable logistic regression estimated the association between spine injury and opioid misuse when adjusting for each factor group. Results Two hundred eighty-five eligible participants consented of which 258 had baseline injury location data and 224 had follow up opioid misuse data. Most participants were male (67.8%), white (85.3%) and on average 43.1 years old. One-quarter had a spine injury (25.2%). Of those completing follow-up measures, 14 (6.3%) developed misuse. Treatment factors (injury severity, intubation, and hospital length of stay) were significantly associated with spine injury. Spine injury significantly predicted opioid misuse [odds ratio [OR] 3.20, 95% confidence interval [CI] (1.05, 9.78)]. In multivariable models, adjusting for treatment factors attenuated the association between spine injury and opioid misuse, primarily explained by length of stay. Conclusion Spine injury exhibits a complex association with opioid misuse that predominantly operates through treatment factors. Spine injury patients may represent a subpopulation requiring early intervention to prevent opioid misuse.
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Affiliation(s)
- Alyssa Shell Tilhou
- Department of Family Medicine, Boston University/Boston Medical Center, Boston, MA
| | - Joseph E Glass
- Kaiser Permanente Washington Health Research Group, Seattle, WA
| | - Scott J Hetzel
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health
| | | | - Tudor Borza
- Departments of Urology and Surgery, University of Wisconsin School of Medicine and Public Health
| | - Amelia Baltes
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Bri M F Deyo
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Ann O'Rourke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health
| | - Randall T Brown
- Department of Family Medicine and Community Health, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Sherrer R, Su R, O'Kelly F, Borza T, Byrne A, Finup J, Farhat W. A Prospective Analysis of Opioid Use Following Outpatient Pediatric Urologic Surgery. Urology 2022; 168:183-188. [PMID: 35853508 DOI: 10.1016/j.urology.2022.07.006] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 06/27/2022] [Accepted: 07/04/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To examine our outpatient urologic surgery cohort for trends in opioid consumption, given the lack of consensus on opioid prescription after outpatient urologic procedures. While opioids have a role in multimodal post-operative analgesia, there is emerging data that they may not be routinely required after pediatric surgery. METHODS Data on opioid use was prospectively collected over 16 months via post-operative telephone calls to caregivers of patients undergoing outpatient urologic surgery. Patient characteristics, surgery type, analgesia, and opioid prescription and usage information were recorded. Patients were prescribed as needed oxycodone and scheduled acetaminophen and ibuprofen for 48 hours, then as needed. The relationships between the log mean of the number of opioid doses used and age, type of surgery, race, and opioid prescription were modelled using negative binomial regression with robust standard errors. RESULTS 265 patients were included. They were predominantly male with median age 2.6 years. The mean number of opioid doses prescribed per patient was 5.8 (SD 2.8, range 3-20). Over half of patients used no opioids, and mean opioid use was one dose. Those prescribed >5 doses took on average 3.4 times more doses compared to those prescribed >5 (p=0.0003), and this was the only factor significantly associated with amount of opioid used. CONCLUSIONS Our findings suggest that opioids are over-prescribed after outpatient pediatric urologic surgery, with 95% of patients having leftover medication and 54% not using any opioids at all. While opioid requirements were low across all sub-cohorts, patients who were prescribed more opioid doses used significantly more doses.
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Affiliation(s)
- Rachael Sherrer
- Department of Urology, University of Wisconsin, Madison, WI.
| | - Ruthie Su
- Department of Urology, University of Wisconsin, Madison, WI.
| | - Fardod O'Kelly
- Division of Paediatric Urology, Beacon Hospital Dublin & University College Dublin, Ireland.
| | - Tudor Borza
- Department of Urology, University of Wisconsin, Madison, WI; Wisconsin Surgical Outcome Research Program, Madison, WI.
| | - Ann Byrne
- Department of Urology, University of Wisconsin, Madison, WI.
| | - Jennika Finup
- Department of Urology, University of Wisconsin, Madison, WI.
| | - Walid Farhat
- Department of Urology, University of Wisconsin, Madison, WI.
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Rose A, Warden A, Best S, Borza T, Tadakala V, Abel EJ, Shapiro DD, Jarrard DF, Richards KA. MP02-19 PROSPECTIVE RANDOMIZED CLINICAL TRIAL TO ASSESS THE UTILITY OF URINALYSIS PRIOR TO OFFICE UROLOGY PROCEDURES. J Urol 2022. [DOI: 10.1097/ju.0000000000002514.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Eaton C, Sutton K, Mote BE, Burkey TE, Borza T, Loy JD, Ciobanu DC. 2 5’ Untranslated Region-Based Detection of Genetically Diverse APPV Strains in US Midwest. J Anim Sci 2022. [DOI: 10.1093/jas/skac064.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] Open
Abstract
Abstract
Atypical porcine pestivirus (APPV), an RNA virus member of the Flaviviridae family, has been associated with congenital tremor in newborn piglets. Previous qPCR-based assays, targeting the polyprotein coding sequences of APPV, were unable to detect the virus in novel cases of congenital tremor originated from multiple swine farms from the U.S. Midwest (MW). The polyprotein coding genes of APPV were characterized by a low level of sequence conservation ranging from 58.2 to 70.7% among 15 global APPV strains. In contrast, the 5’ untranslated region (UTR) was found to have a much greater degree of sequence conservation of 81.0% seen among the 15 global and new 4 MW strains, and as high as 91.5% when comparing only 5 MW strains. The complete 5’ UTR sequence of the APPV strains originated from MW was obtained by utilizing the template switching approach followed by amplification and dideoxy sequencing. Notably, previously identified potentially crucial regions for the correct function of the APPV internal ribosome entry site (IRES) were found to overlap with the most highly conserved 5’UTR segments, suggesting their functional role in viral protein translation. By targeting 100% conserved 5’UTR regions across 19 global and MW strains, a new qPCR assay was designed which was able to detect APPV in well documented cases of congenital tremor which originated from 5 MW farm sites (1-18 samples/site). The assay was found to have a detection sensitivity of 6.5 APPV copies (Cq ~38.4). Due to the potential functional importance of the highly conserved 5’UTR sequences targeted by our newly developed qPCR assay, we expect that assays targeting this region would broadly detect APPV strains that are diverse in space and time.
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Sutton KM, Eaton CW, Borza T, Burkey TE, Mote BE, Loy JD, Ciobanu DC. Genetic Diversity and Detection of Atypical Porcine Pestivirus Infections1. J Anim Sci 2021; 100:6449490. [PMID: 34865057 DOI: 10.1093/jas/skab360] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/01/2021] [Indexed: 11/13/2022] Open
Abstract
Atypical porcine pestivirus (APPV), an RNA virus member of the Flaviviridae family, has been associated with congenital tremor in newborn piglets. Previously reported qPCR-based assays were unable to detect APPV in novel cases of congenital tremor originated from multiple farms from U.S. Midwest (MW). These assays targeted the viral polyprotein coding genes, which were shown to display substantial variation, with sequence identity ranging from 58.2 to 70.7% among 15 global APPV strains. In contrast, the 5' UTR was found to have a much higher degree of sequence conservation. In order to obtain the complete 5' UTR of the APPV strains originated from MW, the 5' end of the viral cDNA was obtained by using template switching approach followed by amplification and dideoxy sequencing. Eighty one percent of the 5'UTR was identical across 14 global and 5 MW strains with complete, or relatively complete 5' UTR. Notably, some of the most highly conserved 5'UTR segments overlapped with potentially important regions of an internal ribosome entry site (IRES), suggesting their functional role in viral protein translation. A newly designed single qPCR assay, targeting 100% conserved 5'UTR regions across 19 strains, was able to detect APPV in samples of well documented cases of congenital tremor which originated from five MW farm sites (1-18 samples/site). As these fully conserved 5' UTR sequences may have functional importance, we expect that assays targeting this region would broadly detect APPV strains that are diverse in space and time.
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Affiliation(s)
- Kylee M Sutton
- Animal Science Department, University of Nebraska-Lincoln, Lincoln, NE 68583, USA.,School of Biological Sciences, University of Nebraska-Lincoln, Lincoln, NE 68502, USA
| | - Christian W Eaton
- Animal Science Department, University of Nebraska-Lincoln, Lincoln, NE 68583, USA.,School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE 68583, USA
| | - Tudor Borza
- Department of Plant, Food and Environmental Sciences, Faculty of Agriculture, Dalhousie University, Truro, B2N 5E3, Canada
| | - Thomas E Burkey
- Animal Science Department, University of Nebraska-Lincoln, Lincoln, NE 68583, USA
| | - Benny E Mote
- Animal Science Department, University of Nebraska-Lincoln, Lincoln, NE 68583, USA
| | - J Dustin Loy
- Veterinary Diagnostic Center, School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE 68583, USA
| | - Daniel C Ciobanu
- Animal Science Department, University of Nebraska-Lincoln, Lincoln, NE 68583, USA
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Krieger JR, Lee FT, McCormick T, Ziemlewicz TJ, Hinshaw JL, Wells SA, Laeseke PE, Stratchko L, Alexander M, Hedican SP, Best SL, Borza T, Nakada SY, Abel EJ. Microwave Ablation of Renal Cell Carcinoma. J Endourol 2021; 35:S33-S37. [PMID: 34499558 DOI: 10.1089/end.2020.1078] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Management options for small renal masses include active surveillance, partial nephrectomy, radical nephrectomy, and thermal ablation. For tumors typically ≤3 cm in size, thermal ablation is a good option for those desiring an alternative to surgery or active surveillance, especially in patients who are considered high surgical risk. We favor microwave ablation because of the more rapid heating, higher temperatures that overcome the heat sink effect of vessels, reproducible cell kill, and a highly visible ablation zone formed by water vapor that corresponds well to the zone of necrosis. For central tumors, we favor cryoablation because of the slower formation of the ablation zone and less likelihood of damage to the collecting system. With microwaves, it is important to monitor the ablation zone in real time (ultrasound is the best modality for this purpose), avoid direct punctures of the collecting system, and to place probes tangential to the collecting system to avoid burning open a persistent tract between the urothelium and extrarenal spaces or causing strictures. The surgical steps described in this video cover our use of high-frequency jet ventilation with general anesthesia to minimize organ motion, initial imaging and targeting, probe insertion, hydrodissection (a technique that enables displacement of adjacent structures), the ablation itself, and finally our dressing. Postoperative cares typically consist of observation with a same-day discharge or an overnight stay. Follow-up includes a magnetic resonance imaging abdomen with and without contrast, chest X-ray, and laboratories (basic metabolic panel, complete blood count, and C-reactive protein) 6 months postablation. Overall, percutaneous microwave ablation is an effective and safe treatment option for renal cell carcinoma in both T1a and T1b tumors in selected patients with multiple studies showing excellent oncologic outcomes when compared with partial and radical nephrectomy.
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Affiliation(s)
- Jordan R Krieger
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Fred T Lee
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Timothy McCormick
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Timothy J Ziemlewicz
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - J Louis Hinshaw
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Shane A Wells
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Paul E Laeseke
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Lindsay Stratchko
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Marci Alexander
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sean P Hedican
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sara L Best
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Tudor Borza
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Stephen Y Nakada
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - E Jason Abel
- Departments of Urology and Radiology, The University of Wisconsin-Madison, Madison, Wisconsin, USA
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Sessine MS, Das S, Park B, Salami SS, Kaffenberger SD, Kasputis A, Solorzano M, Luke M, Vince RA, Kaye DR, Borza T, Stoffel EM, Cobain E, Merajver SD, Jacobs MF, Milliron KJ, Caba L, van Neste L, Mondul AM, Morgan TM. Initial Findings from a High Genetic Risk Prostate Cancer Clinic. Urology 2021; 156:96-103. [PMID: 34280438 DOI: 10.1016/j.urology.2021.05.078] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/06/2021] [Accepted: 05/11/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To improve prostate cancer screening for high-risk men, we developed an early detection clinic for patients at high genetic risk of developing prostate cancer. Despite the rapidly growing understanding of germline variants in driving aggressive prostate cancer and the increased availability of genetic testing, there is little evidence surrounding how best to screen these men. METHODS We are reporting on the first 45 patients enrolled, men between the ages of 35-75, primarily with known pathogenic germline variants in prostate cancer susceptibility genes. Screening consists of an intake lifestyle survey, PSA, DRE, and SelectMDx urine assay. A biopsy was recommended for any of the following indications: 1) abnormal DRE, 2) PSA above threshold, or 3) SelectMDx above threshold. The primary outcomes were number needed to screen, and number needed to biopsy to diagnose a patient with prostate cancer. RESULTS Patients enrolled in the clinic included those with BRCA1 (n=7), BRCA2 (n=16), Lynch Syndrome (n=6), and CHEK2 (n = 4) known pathogenic germline variants. The median age and PSA were 58 (range 35-71) and 1.4 ng/ml (range 0.1-11.4 ng/ml), respectively. 12 patients underwent a prostate needle biopsy and there were 4positive biopsies for prostate cancer. CONCLUSION These early data support the feasibility of opening a dedicated clinic for men at high genetic risk of prostate cancer. This early report on the initial enrollment of our long-term study will help optimize early detection protocols and provide evidence for personalized prostate cancer screening in men with key pathogenic germline variants.
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Affiliation(s)
| | - Sanjay Das
- Department of Urology, Michigan Medicine
| | - Bumsoo Park
- Department of Urology, Michigan Medicine; Department of Family Medicine, Michigan Medicine
| | | | | | | | | | | | | | | | - Tudor Borza
- Department of Urology, University of Wisconsin School of Medicine and Public Health; Division of Urology, William S Middleton Memorial Veterans Hospital
| | | | - Erin Cobain
- Medical Genetics, Rogel Cancer Center, Michigan Medicine
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14
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Han X, Xi Y, Zhang Z, Mohammadi MA, Joshi J, Borza T, Wang-Pruski G. Effects of phosphite as a plant biostimulant on metabolism and stress response for better plant performance in Solanum tuberosum. Ecotoxicol Environ Saf 2021; 210:111873. [PMID: 33418157 DOI: 10.1016/j.ecoenv.2020.111873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 05/26/2023]
Abstract
Food availability represents a major worldwide concern due to population growth, increased demand, and climate change. Therefore, it is imperative to identify compounds that can improve crop performance. Plant biostimulants have gained prominence because of their potentials to increase germination, productivity and quality of a wide range of horticultural and agronomic crops. Phosphite (Phi), an analog of orthophosphate, is an emerging biostimulant used in horticulture and agronomy. The aim of this study was to uncover the molecular mechanisms through which Phi acts as a biostimulant with potential effects of overall plant growth. Field and greenhouse experiments, using 4 potato cultivars, showed that following Phi applications, plant performance, including several physio-biochemical traits, crop productivity, and quality traits, were significantly improved. RNA sequencing of control and Phi-treated plants of cultivar Xingjia No. 2, at 0 h, 6 h, 24 h, 48 h, 72 h and 96 h after the Phi application for 24 h revealed extensive changes in the gene expression profiles. A total of 2856 differentially expressed genes were identified, suggesting that multiple pathways of primary and secondary metabolism, such as flavonoids biosynthesis, starch and sucrose metabolism, and phenylpropanoid biosynthesis, were strongly influenced by foliar applications of Phi. GO (Gene Ontology) and KEGG (Kyoto Encyclopedia of Genes and Genomes) enrichment analyses associated with defense responses revealed significant effects of Phi on a plethora of defense mechanisms. These results suggest that Phi acted as a biostimulant by priming the plants, that was, by triggering dynamic changes in gene expression and modulating metabolic fluxes in a way that allowed plants to perform better. Therefore, Phi usage has the potential to improve crop yield and health, alleviating the challenges posed by the need of feeding a growing world population, while minimizing the agricultural impact on human health and environment.
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Affiliation(s)
- Xiaoyun Han
- Joint FAFU-Dalhousie Lab, College of Horticulture, Fujian Agriculture and Forestry University, Fuzhou 350002, China
| | - Yupei Xi
- Joint FAFU-Dalhousie Lab, College of Horticulture, Fujian Agriculture and Forestry University, Fuzhou 350002, China
| | - Zhizhong Zhang
- Joint FAFU-Dalhousie Lab, College of Horticulture, Fujian Agriculture and Forestry University, Fuzhou 350002, China
| | - Mohammad Aqa Mohammadi
- Joint FAFU-Dalhousie Lab, College of Horticulture, Fujian Agriculture and Forestry University, Fuzhou 350002, China
| | - Jyoti Joshi
- Department of Plant, Food, and Environmental Sciences, Faculty of Agriculture, Dalhousie University, Truro, NS B2N 5E3, Canada
| | - Tudor Borza
- Department of Plant, Food, and Environmental Sciences, Faculty of Agriculture, Dalhousie University, Truro, NS B2N 5E3, Canada
| | - Gefu Wang-Pruski
- Joint FAFU-Dalhousie Lab, College of Horticulture, Fujian Agriculture and Forestry University, Fuzhou 350002, China; Department of Plant, Food, and Environmental Sciences, Faculty of Agriculture, Dalhousie University, Truro, NS B2N 5E3, Canada.
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15
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Rathor P, Borza T, Stone S, Tonon T, Yurgel S, Potin P, Prithiviraj B. A Novel Protein from Ectocarpus sp. Improves Salinity and High Temperature Stress Tolerance in Arabidopsis thaliana. Int J Mol Sci 2021; 22:1971. [PMID: 33671243 PMCID: PMC7922944 DOI: 10.3390/ijms22041971] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/11/2021] [Accepted: 02/13/2021] [Indexed: 11/16/2022] Open
Abstract
Brown alga Ectocarpus sp. belongs to Phaeophyceae, a class of macroalgae that evolved complex multicellularity. Ectocarpus sp. is a dominant seaweed in temperate regions, abundant mostly in the intertidal zones, an environment with high levels of abiotic stresses. Previous transcriptomic analysis of Ectocarpus sp. revealed several genes consistently induced by various abiotic stresses; one of these genes is Esi0017_0056, which encodes a protein with unknown function. Bioinformatics analyses indicated that the protein encoded by Esi0017_0056 is soluble and monomeric. The protein was successfully expressed in Escherichia coli,Arabidopsis thaliana and Nicotiana benthamiana. In A. thaliana the gene was expressed under constitutive and stress inducible promoters which led to improved tolerance to high salinity and temperature stresses. The expression of several key abiotic stress-related genes was studied in transgenic and wild type A. thaliana by qPCR. Expression analysis revealed that genes involved in ABA-induced abiotic stress tolerance, K+ homeostasis, and chaperon activities were significantly up-regulated in the transgenic line. This study is the first report in which an unknown function Ectocarpus sp. gene, highly responsive to abiotic stresses, was successfully expressed in A. thaliana, leading to improved tolerance to salt and temperature stress.
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Affiliation(s)
- Pramod Rathor
- Department of Plant, Food and Environmental Sciences, Dalhousie University, Truro, NS B2N 5E3, Canada; (P.R.); (T.B.); (S.Y.)
| | - Tudor Borza
- Department of Plant, Food and Environmental Sciences, Dalhousie University, Truro, NS B2N 5E3, Canada; (P.R.); (T.B.); (S.Y.)
| | - Sophia Stone
- Department of Biology, Dalhousie University, Halifax, NS B3H 4R2, Canada;
| | - Thierry Tonon
- Centre for Novel Agricultural Products, Department of Biology, University of York, Heslington, York YO10 5DD, UK;
- Integrative Biology of Marine Models (LBI2M), Station Biologique de Roscoff (SBR), Sorbonne Université, CNRS, UMR 8227, 29680 Roscoff, France;
| | - Svetlana Yurgel
- Department of Plant, Food and Environmental Sciences, Dalhousie University, Truro, NS B2N 5E3, Canada; (P.R.); (T.B.); (S.Y.)
| | - Philippe Potin
- Integrative Biology of Marine Models (LBI2M), Station Biologique de Roscoff (SBR), Sorbonne Université, CNRS, UMR 8227, 29680 Roscoff, France;
| | - Balakrishnan Prithiviraj
- Department of Plant, Food and Environmental Sciences, Dalhousie University, Truro, NS B2N 5E3, Canada; (P.R.); (T.B.); (S.Y.)
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16
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Shukla PS, Borza T, Critchley AT, Prithiviraj B. Seaweed-Based Compounds and Products for Sustainable Protection against Plant Pathogens. Mar Drugs 2021; 19:59. [PMID: 33504049 PMCID: PMC7911005 DOI: 10.3390/md19020059] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 12/16/2022] Open
Abstract
Sustainable agricultural practices increasingly demand novel, environmentally friendly compounds which induce plant immunity against pathogens. Stimulating plant immunity using seaweed extracts is a highly viable strategy, as these formulations contain many bio-elicitors (phyco-elicitors) which can significantly boost natural plant immunity. Certain bioactive elicitors present in a multitude of extracts of seaweeds (both commercially available and bench-scale laboratory formulations) activate pathogen-associated molecular patterns (PAMPs) due to their structural similarity (i.e., analogous structure) with pathogen-derived molecules. This is achieved via the priming and/or elicitation of the defense responses of the induced systemic resistance (ISR) and systemic acquired resistance (SAR) pathways. Knowledge accumulated over the past few decades is reviewed here, aiming to explain why certain seaweed-derived bioactives have such tremendous potential to elicit plant defense responses with considerable economic significance, particularly with increasing biotic stress impacts due to climate change and the concomitant move to sustainable agriculture and away from synthetic chemistry and environmental damage. Various extracts of seaweeds display remarkably different modes of action(s) which can manipulate the plant defense responses when applied. This review focuses on both the similarities and differences amongst the modes of actions of several different seaweed extracts, as well as their individual components. Novel biotechnological approaches for the development of new commercial products for crop protection, in a sustainable manner, are also suggested.
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Affiliation(s)
- Pushp Sheel Shukla
- Marine Bio-Products Research Laboratory, Department of Plant, Food and Environmental Sciences, Faculty of Agriculture, Dalhousie University, Truro, NS B2N5E3, Canada; (P.S.S.); (T.B.)
| | - Tudor Borza
- Marine Bio-Products Research Laboratory, Department of Plant, Food and Environmental Sciences, Faculty of Agriculture, Dalhousie University, Truro, NS B2N5E3, Canada; (P.S.S.); (T.B.)
| | - Alan T. Critchley
- Verschuren Centre for Sustainability in Energy and Environment, Cape Breton University, Sydney, NS B1M1A2, Canada;
| | - Balakrishnan Prithiviraj
- Marine Bio-Products Research Laboratory, Department of Plant, Food and Environmental Sciences, Faculty of Agriculture, Dalhousie University, Truro, NS B2N5E3, Canada; (P.S.S.); (T.B.)
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17
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Serrell EC, Greenberg CC, Borza T. EDITORIAL COMMENT. Urology 2020; 145:125-126. [PMID: 33167170 DOI: 10.1016/j.urology.2020.05.098] [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: 11/15/2022]
Affiliation(s)
- Emily C Serrell
- Departments of Urology, University of Wisconsin, Madison, WI
| | | | - Tudor Borza
- Departments of Urology, University of Wisconsin, Madison, WI; Surgery, University of Wisconsin, Madison, WI
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18
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Rathor P, Borza T, Liu Y, Qin Y, Stone S, Zhang J, Hui JPM, Berrue F, Groisillier A, Tonon T, Yurgel S, Potin P, Prithiviraj B. Low Mannitol Concentrations in Arabidopsis thaliana Expressing Ectocarpus Genes Improve Salt Tolerance. Plants (Basel) 2020; 9:plants9111508. [PMID: 33171775 PMCID: PMC7695032 DOI: 10.3390/plants9111508] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 11/16/2022]
Abstract
Mannitol is abundant in a wide range of organisms, playing important roles in biotic and abiotic stress responses. Nonetheless, mannitol is not produced by a vast majority of plants, including many important crop plants. Mannitol-producing transgenic plants displayed improved tolerance to salt stresses though mannitol production was rather low, in the µM range, compared to mM range found in plants that innately produce mannitol. Little is known about the molecular mechanisms underlying salt tolerance triggered by low concentrations of mannitol. Reported here is the production of mannitol in Arabidopsis thaliana, by expressing two mannitol biosynthesis genes from the brown alga Ectocarpus sp. strain Ec32. To date, no brown algal genes have been successfully expressed in land plants. Expression of mannitol-1-phosphate dehydrogenase and mannitol-1-phosphatase genes was associated with the production of 42.3–52.7 nmol g−1 fresh weight of mannitol, which was sufficient to impart salinity and temperature stress tolerance. Transcriptomics revealed significant differences in the expression of numerous genes, in standard and salinity stress conditions, including genes involved in K+ homeostasis, ROS signaling, plant development, photosynthesis, ABA signaling and secondary metabolism. These results suggest that the improved tolerance to salinity stress observed in transgenic plants producing mannitol in µM range is achieved by the activation of a significant number of genes, many of which are involved in priming and modulating the expression of genes involved in a variety of functions including hormone signaling, osmotic and oxidative stress, and ion homeostasis.
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Affiliation(s)
- Pramod Rathor
- Marine Bioproducts Research Laboratory, Department of Plant, Food and Environmental Sciences, Dalhousie University, Truro, NS B2N 5E3, Canada; (P.R.); (T.B.); (S.Y.)
| | - Tudor Borza
- Marine Bioproducts Research Laboratory, Department of Plant, Food and Environmental Sciences, Dalhousie University, Truro, NS B2N 5E3, Canada; (P.R.); (T.B.); (S.Y.)
| | - Yanhui Liu
- Fujian Provincial Key Laboratory of Haixia Applied Plant Systems Biology, State Key Laboratory of Ecological Pest Control for Fujian and Taiwan Crops, Center for Genomics and Biotechnology, College of Life Science, Fujian Agriculture and Forestry University, Fuzhou 350002, China; (Y.L.); (Y.Q.)
| | - Yuan Qin
- Fujian Provincial Key Laboratory of Haixia Applied Plant Systems Biology, State Key Laboratory of Ecological Pest Control for Fujian and Taiwan Crops, Center for Genomics and Biotechnology, College of Life Science, Fujian Agriculture and Forestry University, Fuzhou 350002, China; (Y.L.); (Y.Q.)
| | - Sophia Stone
- Department of Biology, Dalhousie University, Halifax, NS B3H 4R2, Canada;
| | - Junzeng Zhang
- Aquatic and Crop Resource Development Research Centre, National Research Council of Canada, Halifax, NS B3H 3Z1, Canada; (J.Z.); (J.P.M.H.); (F.B.)
| | - Joseph P. M. Hui
- Aquatic and Crop Resource Development Research Centre, National Research Council of Canada, Halifax, NS B3H 3Z1, Canada; (J.Z.); (J.P.M.H.); (F.B.)
| | - Fabrice Berrue
- Aquatic and Crop Resource Development Research Centre, National Research Council of Canada, Halifax, NS B3H 3Z1, Canada; (J.Z.); (J.P.M.H.); (F.B.)
| | - Agnès Groisillier
- Unité Fonctionnalité et Ingénierie des Protéines (UFIP), UMR 6286 CNRS, Université de Nantes, 44322 Nantes, France;
| | - Thierry Tonon
- Centre for Novel Agricultural Products, Department of Biology, University of York, Heslington YO105DD, UK;
- Sorbonne Université, CNRS, UMR 8227, Integrative Biology of Marine Models (LBI2M), Station Biologique, 29680 Roscoff, France;
| | - Svetlana Yurgel
- Marine Bioproducts Research Laboratory, Department of Plant, Food and Environmental Sciences, Dalhousie University, Truro, NS B2N 5E3, Canada; (P.R.); (T.B.); (S.Y.)
| | - Philippe Potin
- Sorbonne Université, CNRS, UMR 8227, Integrative Biology of Marine Models (LBI2M), Station Biologique, 29680 Roscoff, France;
| | - Balakrishnan Prithiviraj
- Marine Bioproducts Research Laboratory, Department of Plant, Food and Environmental Sciences, Dalhousie University, Truro, NS B2N 5E3, Canada; (P.R.); (T.B.); (S.Y.)
- Correspondence:
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19
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Serrell EC, Greenberg CC, Borza T. Surgeons and perioperative opioid prescribing: An underappreciated contributor to the opioid epidemic. Cancer 2020; 127:184-187. [PMID: 33002194 DOI: 10.1002/cncr.33199] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/17/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Emily C Serrell
- Department of Urology, University of Wisconsin, Madison, Wisconsin
| | - Caprice C Greenberg
- Department of Surgery, University of Wisconsin, Madison, Wisconsin.,Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, Wisconsin
| | - Tudor Borza
- Department of Urology, University of Wisconsin, Madison, Wisconsin.,Department of Surgery, University of Wisconsin, Madison, Wisconsin.,Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, Wisconsin
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20
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Urish KL, Qin Y, Salka B, Li BY, Borza T, Sessine M, Kirk P, Hollenbeck BK, Helm JE, Lavieri MS, Skolarus TA, Jacobs BL. Comparison of readmission and early revision rates as a quality metric in total knee arthroplasty using the Nationwide Readmission Database. Ann Transl Med 2020; 8:687. [PMID: 32617307 PMCID: PMC7327322 DOI: 10.21037/atm-19-3463] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background After release of the Comprehensive Care for Joint Replacement bundle, there has been increased emphasis on reducing readmission rates for total knee arthroplasty (TKA). The potential for a separate, clinically-relevant metric, TKA revision rates within a year following surgery, has not been fully explored. Based on this, we compared rates and payments for TKA readmission and revision procedures as metrics for improving quality and cost. Methods We utilized the 2013 Nationwide Readmission Database (NRD) to examine national readmission and revision rates, the reasons for revision procedures, and associated costs for elective TKA procedures. As data are not linked across years, we examined revision rates for TKA completed in the month of January by capturing revision procedures in the subsequent following 11-month period to approximate a 1-year revision rate. Diagnosis and procedure codes for revision procedures were collected. Average readmission and revision procedure costs were then calculated, and the cost distributed across the entire TKA population. Results We identified 20,851 patients having TKA surgery. The mean unadjusted 30- and 90-day TKA readmission rates were 3.4% and 5.8%, respectively. In contrast, the mean unadjusted 3-month and approximate 1-year reoperation rates were 1.0% and 1.6%, respectively. The most common cause for revision was periprosthetic joint infection, which accounting for 62% of all reported revision procedures. The mean payment for 90-day readmission was roughly half ($10,589±$11,084) of the mean inpatient payment for single reoperation procedure at 90 days ($20,222±$17,799). Importantly, nearly half (46%) of all 90-day readmissions were associated with a reoperation event within the first year. Conclusions Readmission following TKA is associated with a 1-year reoperation in approximately half of patients. These reoperations represent a significant patient burden and have a higher per episode cost. Early reoperation may represent a more clinically relevant target for quality improvement and cost containment.
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Affiliation(s)
- Kenneth L Urish
- Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Orthopaedic Surgery, Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Yongmei Qin
- Department of Urology, Division of Oncology, Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI, USA
| | - Bassel Salka
- Department of Urology, Division of Oncology, Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI, USA
| | - Benjamin Y Li
- Department of Urology, Division of Oncology, Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI, USA
| | - Tudor Borza
- Department of Urology, University of Wisconsin School of Medicine and Public Health, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Michael Sessine
- Department of Urology, Division of Oncology, Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI, USA
| | - Peter Kirk
- Department of Urology, Division of Oncology, Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI, USA
| | - Brent K Hollenbeck
- Department of Urology, Division of Oncology, Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI, USA
| | - Jonathan E Helm
- Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Mariel S Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Department of Urology, Division of Oncology, Dow Division for Urologic Health Service Research, Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI, USA
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, PA, USA
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21
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Affiliation(s)
| | - Tudor Borza
- Department of Urology, University of Wisconsin, Madison, WI; Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, WI; William S. Middleton Memorial Veterans Hospital, Madison, WI
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22
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Sessine MS, Weizer A, Kirk PS, Borza T, Jacobs BL, Qin Y, Oerline M, Li B, Modi PK, Lavieri MS, Gilbert SM, Montgomery JS, Hollenbeck BK, Urish K, Helm JE, Skolarus TA. Reframing Financial Incentives Around Reducing Readmission After Radical Cystectomy. Urology 2020; 142:99-105. [PMID: 32413517 DOI: 10.1016/j.urology.2020.03.059] [Citation(s) in RCA: 1] [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] [Received: 11/24/2019] [Revised: 02/29/2020] [Accepted: 03/29/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To better understand the financial implications of readmission after radical cystectomy, an expensive surgery coupled with a high readmission rate. Currently, whether hospitals benefit financially from readmissions after radical cystectomy remains unclear, and potentially obscures incentives to invest in readmission reduction efforts. MATERIALS AND METHODS Using a 20% sample of national Medicare beneficiaries, we identified 3544 patients undergoing radical cystectomy from January 2010 to November 2014. We compared price-standardized Medicare payments for index admissions and readmissions after surgery. We also examined the variable financial impact of length of stay and the proportion of Medicare payments coming from readmissions based on overall readmission rate. RESULTS Medicare patients readmitted after cystectomy had higher index hospitalization payments ($19,164 readmitted vs $18,146 non-readmitted, P = .03) and an average readmission payment of $7356. Adjusted average Medicare readmission payments and length of stay varied significantly across hospitals, ranging from $2854 to $15,605, and 2.0 to 17.1 days, respectively (both P <.01), with longer length of stay associated with increased payments. After hospitals were divided into quartiles based on overall readmission rates, the percent of payments coming from readmissions ranged from 5% to 13%. CONCLUSION Readmissions following radical cystectomy were associated with increased Medicare payments for the index hospitalization, and the readmission payment, potentially limiting incentives for readmission reduction programs. Our findings highlight opportunities to reframe efforts to support patients, caregivers, and providers through improving the discharge and readmission processes to create a patient-centered experience, rather than for fear of financial penalties.
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Affiliation(s)
- Michael S Sessine
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Alon Weizer
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Peter S Kirk
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Tudor Borza
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI; Division of Urology, William S. Middleton Memorial Veterans Hospital, Madison, WI
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Yongmei Qin
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Mary Oerline
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Benjamin Li
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Parth K Modi
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Mariel S Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI
| | - Scott M Gilbert
- Department of Urology, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Jeffrey S Montgomery
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Ken Urish
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jonathan E Helm
- Department of Operations and Decision Technologies, Kelley School of Business, Indiana University, Bloomington, IN
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI; VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI.
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23
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Xi Y, Han X, Zhang Z, Joshi J, Borza T, Mohammad Aqa M, Zhang B, Yuan H, Wang-Pruski G. Exogenous phosphite application alleviates the adverse effects of heat stress and improves thermotolerance of potato (Solanum tuberosum L.) seedlings. Ecotoxicol Environ Saf 2020; 190:110048. [PMID: 31837570 DOI: 10.1016/j.ecoenv.2019.110048] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 11/25/2019] [Accepted: 12/02/2019] [Indexed: 05/07/2023]
Abstract
Phosphite (Phi), an analog of phosphate (Pi) anion, is emerging as a potential biostimulator, fungicide and insecticide. Here, we reported that Phi also significantly enhanced thermotolerance in potatoes under heat stress. Potato plants with and without Phi pretreatment were exposed to heat stress and their heat tolerance was examined by assessing the morphological characteristics, photosynthetic pigment content, photosystem II (PS II) efficiency, levels of oxidative stress, and level of DNA damage. In addition, RNA-sequencing (RNA-Seq) was adopted to investigate the roles of Phi signals and the underlying heat resistance mechanism. RNA-Seq revealed that Phi orchestrated plant immune responses against heat stress by reprograming global gene expressions. Results from physiological data combined with RNA-Seq suggested that the supply of Phi not only was essential for the better plant performance, but also improved thermotolerance of the plants by alleviating oxidative stress and DNA damage, and improved biosynthesis of osmolytes and defense metabolites when exposed to unfavorable thermal conditions. This is the first study to explore the role of Phi in thermotolerance in plants, and the work can be applied to other crops under the challenging environment.
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Affiliation(s)
- Yupei Xi
- Joint FAFU-Dalhousie Lab, College of Horticulture, Fujian Agriculture and Forestry University, Fuzhou, 350002, China
| | - Xiaoyun Han
- Joint FAFU-Dalhousie Lab, College of Horticulture, Fujian Agriculture and Forestry University, Fuzhou, 350002, China
| | - Zhizhong Zhang
- Joint FAFU-Dalhousie Lab, College of Horticulture, Fujian Agriculture and Forestry University, Fuzhou, 350002, China
| | - Jyoti Joshi
- Department of Plant, Food and Environmental Sciences, Faculty of Agriculture, Dalhousie University, Truro, NS B2N 5E3, Canada
| | - Tudor Borza
- Department of Plant, Food and Environmental Sciences, Faculty of Agriculture, Dalhousie University, Truro, NS B2N 5E3, Canada
| | - Mohammadi Mohammad Aqa
- Joint FAFU-Dalhousie Lab, College of Horticulture, Fujian Agriculture and Forestry University, Fuzhou, 350002, China
| | - Beibei Zhang
- Joint FAFU-Dalhousie Lab, College of Horticulture, Fujian Agriculture and Forestry University, Fuzhou, 350002, China
| | - Huimin Yuan
- Joint FAFU-Dalhousie Lab, College of Horticulture, Fujian Agriculture and Forestry University, Fuzhou, 350002, China
| | - Gefu Wang-Pruski
- Joint FAFU-Dalhousie Lab, College of Horticulture, Fujian Agriculture and Forestry University, Fuzhou, 350002, China; Department of Plant, Food and Environmental Sciences, Faculty of Agriculture, Dalhousie University, Truro, NS B2N 5E3, Canada.
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24
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Kirk PS, Liu X, Borza T, Li BY, Sessine M, Zhu K, Lesse O, Qin Y, Jacobs B, Urish K, Helm J, Gilbert S, Weizer A, Montgomery J, Hollenbeck BK, Lavieri M, Skolarus TA. Dynamic readmission prediction using routine postoperative laboratory results after radical cystectomy. Urol Oncol 2020; 38:255-261. [PMID: 31953004 DOI: 10.1016/j.urolonc.2019.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 10/19/2019] [Accepted: 11/25/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine if the addition of electronic health record data enables better risk stratification and readmission prediction after radical cystectomy. Despite efforts to reduce their frequency and severity, complications and readmissions following radical cystectomy remain common. Leveraging readily available, dynamic information such as laboratory results may allow for improved prediction and targeted interventions for patients at risk of readmission. METHODS We used an institutional electronic medical records database to obtain demographic, clinical, and laboratory data for patients undergoing radical cystectomy. We characterized the trajectory of common postoperative laboratory values during the index hospital stay using support vector machine learning techniques. We compared models with and without laboratory results to assess predictive ability for readmission. RESULTS Among 996 patients who underwent radical cystectomy, 259 patients (26%) experienced a readmission within 30 days. During the first week after surgery, median daily values for white blood cell count, urea nitrogen, bicarbonate, and creatinine differentiated readmitted and nonreadmitted patients. Inclusion of laboratory results greatly increased the ability of models to predict 30-day readmissions after cystectomy. CONCLUSIONS Common postoperative laboratory values may have discriminatory power to help identify patients at higher risk of readmission after radical cystectomy. Dynamic sources of physiological data such as laboratory values could enable more accurate identification and targeting of patients at greatest readmission risk after cystectomy. This is a proof of concept study that suggests further exploration of these techniques is warranted.
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Affiliation(s)
- Peter S Kirk
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Xiang Liu
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI
| | - Tudor Borza
- Department of Urology, University of Wisconsin, Madison, WI
| | - Benjamin Y Li
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Michael Sessine
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Kevin Zhu
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Opal Lesse
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Yongmei Qin
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Bruce Jacobs
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ken Urish
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jonathan Helm
- W.P. Carey School of Business, Arizona State University, Tempe, AZ
| | - Scott Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
| | - Alon Weizer
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Jeffrey Montgomery
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI
| | - Mariel Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI; VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI.
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25
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Abstract
OBJECTIVE To compare readmission rates as measured by the Centers for Medicare and Medicaid Services and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) methods. DATA SOURCES 20 percent sample of national Medicare data for patients undergoing cystectomy, colectomy, abdominal aortic aneurysm (AAA) repair, and total knee arthroplasty (TKA) between 2010 and 2014. STUDY DESIGN Retrospective cohort study comparing 30-day readmission rates. DATA COLLECTION/EXTRACTION METHODS Patients undergoing cystectomy, colectomy, abdominal aortic aneurysm repair, and total knee arthroplasty between 2010 and 2014 were identified. PRINCIPAL FINDINGS Cystectomy had the highest and total knee arthroplasty had the lowest readmission rate. The NSQIP measure reported significantly lower rates for all procedures compared to the CMS measure, which reflects an immortal-time bias. CONCLUSIONS We found significantly different readmission rates across all surgical procedures when comparing CMS and NSQIP measures. Longer length of stay exacerbated these differences. Uniform outcome measures are needed to eliminate ambiguity and synergize research and policy efforts.
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Affiliation(s)
- Lee A Hugar
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Tudor Borza
- Dow Health Services Research Division, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Mary K Oerline
- Dow Health Services Research Division, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Brent K Hollenbeck
- Dow Health Services Research Division, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Ted A Skolarus
- Dow Health Services Research Division, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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26
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Sutton KM, Lahmers KK, Harris SP, Wijesena HR, Mote BE, Kachman SD, Borza T, Ciobanu DC. Detection of atypical porcine pestivirus genome in newborn piglets affected by congenital tremor and high preweaning mortality1. J Anim Sci 2019; 97:4093-4100. [PMID: 31396615 DOI: 10.1093/jas/skz267] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 07/03/2019] [Accepted: 08/06/2019] [Indexed: 01/23/2023] Open
Abstract
Recently, piglets from a high-health status farm began exhibiting congenital tremors, high preweaning mortality and incidence of splayed legs. Postmortem histological examination identified a small number of scattered white matter vacuoles in the cerebellum and underlying brainstem of affected piglets. Presence of potential viral sources associated with this neurologic condition was initially infirmed using quantitative PCR for atypical porcine pestivirus (APPV), porcine teschovirus, and porcine sapelovirus. Using metagenomic analysis, APPV was identified as the main microbial species in serum obtained from piglets affected by congenital tremor. These piglets had higher preweaning mortality rates (46.4% vs. 15.3%) and incidence of splayed legs (33.0% vs. 0.8 %) compared to unaffected piglets. Piglets affected by congenital tremor had higher viral titer (P < 0.15) and larger birth weights (P < 0.05) compared to normal litter mates. Whole-genome sequencing and genome assembly of the novel APPV strain (MK728876) was carried out using Oxford Nanopore and related bioinformatics pipelines. Phylogenic analysis demonstrated that this strain along with other completely sequenced APPV strains were grouped into 2 clades, both including strains-inducing congenital tremor. Strains appear to cluster based on region but there were still significant differences within regions. Future research needs to address potential underdiagnosis due to genetic diversity but also to understand mode of transmission, variation in virulence, and the role of host genetics in APPV susceptibility.
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Affiliation(s)
- Kylee M Sutton
- Animal Science Department, University of Nebraska-Lincoln, Lincoln, NE.,School of Biological Sciences, University of Nebraska-Lincoln, Lincoln, NE
| | - Kevin K Lahmers
- Department of Biomedical Sciences and Pathology, Virginia-Maryland College of Veterinary Medicine, Blacksburg, VA.,Virginia Tech Animal Laboratory Services, Virginia-Maryland College of Veterinary Medicine, Blacksburg, VA
| | - Seth P Harris
- Veterinary Diagnostic Center, School of Veterinary Medicine and Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE
| | - Hiruni R Wijesena
- Animal Science Department, University of Nebraska-Lincoln, Lincoln, NE
| | - Benny E Mote
- Animal Science Department, University of Nebraska-Lincoln, Lincoln, NE
| | - Stephen D Kachman
- Department of Statistics, University of Nebraska-Lincoln, Lincoln, NE
| | - Tudor Borza
- Department of Plant, Food and Environmental Sciences, Faculty of Agriculture, Dalhousie University, Truro, Canada
| | - Daniel C Ciobanu
- Animal Science Department, University of Nebraska-Lincoln, Lincoln, NE.,School of Biological Sciences, University of Nebraska-Lincoln, Lincoln, NE
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27
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Macleod LC, Fam MM, Yabes JG, Hale NE, Turner RM, Lopa SH, Gingrich JR, Borza T, Skolarus TA, Davies BJ, Jacobs BL. Comparison of Neoadjuvant and Adjuvant Chemotherapy in Muscle-invasive Bladder Cancer. Clin Genitourin Cancer 2019; 18:201-209.e2. [PMID: 31917172 DOI: 10.1016/j.clgc.2019.12.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 07/15/2019] [Revised: 12/05/2019] [Accepted: 12/09/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND We use observational methods to compare impact of perioperative chemotherapy timing (ie, neoadjuvant and adjuvant) on overall survival (OS) in muscle-invasive bladder cancer because there is no head-to-head randomized trial, and patient factors may influence decision-making. PATIENTS AND METHODS Using Surveillance, Epidemiology, and End Results-Medicare data, we identified patients receiving cystectomy for muscle-invasive bladder cancer diagnosed between 2004 and 2013. Patients were classified as receiving neoadjuvant or adjuvant chemotherapy. Propensity of receiving neoadjuvant chemotherapy was determined using gradient boosted models. Inverse probability of treatment weighted survival curves were adjusted for 13 demographic, socioeconomic, temporal, and oncologic covariates. RESULTS We identified 1342 patients who received neoadjuvant (n = 676) or adjuvant chemotherapy (n = 666) with a median follow-up of 23 months (interquartile range, 9-55 months). Inverse probability of treatment weighted adjustment allows comparison of the groups head-to-head as well as counterfactual scenarios (eg, effect if those getting one treatment were to receive the other). The average treatment effect (ie, "head-to-head" comparison) of adjuvant compared with neoadjuvant on OS was not significant (hazard ratio, 1.14; 95% confidence interval, 0.99-1.31). However, the average treatment effect of the treated (ie, the effect if the neoadjuvant patients were to receive adjuvant instead) was associated with a 33% increase in risk of mortality if they were given adjuvant therapy instead (hazard ratio, 1.33; 95% confidence interval, 1.12-1.57). CONCLUSION Significant treatment selection bias was noted in peri-cystectomy timing, which limits the ability to discriminate differential efficacy of these 2 approaches with observational data. However, patients with higher propensity to receive neoadjuvant therapy were predicted to have increased OS with approach, in keeping with existing paradigms from trial data.
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Affiliation(s)
- Liam C Macleod
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA; Department of Urology, Asante Rogue Regional Medical Center, Medford, OR.
| | - Mina M Fam
- Department of Urology, Jersey Shore University Medical Center, Neptune, NJ
| | - Jonathan G Yabes
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Nathan E Hale
- Department of Urology, Charleston Area Medical Center, Charleston, WV
| | - Robert M Turner
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Samia H Lopa
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Tudor Borza
- Department of Urology, University of Wisconsin, Madison, WI
| | - Ted A Skolarus
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, MI; Dow Division for Urologic Health Service Research, Department of Urology, University of Michigan, Ann Arbor, MI; VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Benjamin J Davies
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
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28
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Hale NE, Macleod LC, Yabes JG, Turner RM, Fam MM, Gingrich JR, Skolarus TA, Borza T, Sabik LM, Davies BJ, Jacobs BL. Implications of Cystectomy Travel Distance for Hospital Readmission and Survival. Clin Genitourin Cancer 2019; 17:e1171-e1180. [DOI: 10.1016/j.clgc.2019.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 08/03/2019] [Accepted: 08/10/2019] [Indexed: 12/19/2022]
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29
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Li BY, Urish KL, Jacobs BL, He C, Borza T, Qin Y, Min HS, Dupree JM, Ellimoottil C, Hollenbeck BK, Lavieri MS, Helm JE, Skolarus TA. Inaugural Readmission Penalties for Total Hip and Total Knee Arthroplasty Procedures Under the Hospital Readmissions Reduction Program. JAMA Netw Open 2019; 2:e1916008. [PMID: 31755949 PMCID: PMC6902819 DOI: 10.1001/jamanetworkopen.2019.16008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE The Hospital Readmissions Reduction Program (HRRP) is a Centers for Medicare and Medicaid Services policy that levies hospital reimbursement penalties based on excess readmissions of patients with 4 medical conditions and 3 surgical procedures. A greater understanding of factors associated with the 3 surgical reimbursement penalties is needed for clinicians in surgical practice. OBJECTIVE To investigate the first year of HRRP readmission penalties applied to 2 surgical procedures-elective total hip arthroplasty (THA) and total knee arthroplasty (TKA)-in the context of hospital and patient characteristics. DESIGN, SETTING, AND PARTICIPANTS Fiscal year 2015 HRRP penalization data from Hospital Compare were linked with the American Hospital Association Annual Survey and with the Healthcare Cost and Utilization Project State Inpatient Database for hospitals in the state of Florida. By using a case-control framework, those hospitals were separated based on HRRP penalty severity, as measured with the HRRP THA and TKA excess readmission ratio, and compared according to orthopedic volume as well as hospital-level and patient-level characteristics. The first year of HRRP readmission penalties applied to surgery in Florida Medicare subsection (d) hospitals was examined, identifying 60 663 Medicare patients who underwent elective THA or TKA in 143 Florida hospitals. The data analysis was conducted from February 2016 to January 2017. EXPOSURES Annual hospital THA and TKA volume, other hospital-level characteristics, and patient factors used in HRRP risk adjustment. MAIN OUTCOMES AND MEASURES The HRRP penalties with HRRP excess readmission ratios were measured, and their association with annual THA and TKA volume, a common measure of surgical quality, was evaluated. The HRRP penalties for surgical care according to hospital and readmitted patient characteristics were then examined. RESULTS Among 143 Florida hospitals, 2991 of 60 663 Medicare patients (4.9%) who underwent THA or TKA were readmitted within 30 days. Annual hospital arthroplasty volume seemed to follow an inverse association with both unadjusted readmission rates (r = -0.16, P = .06) and HRRP risk-adjusted readmission penalties (r = -0.12, P = .14), but these associations were not statistically significant. Other hospital characteristics and readmitted patient characteristics were similar across HRRP orthopedic penalty severity. CONCLUSIONS AND RELEVANCE This study's findings suggest that higher-volume hospitals had less severe, but not significantly different, rates of readmission and HRRP penalties, without systematic differences across readmitted patients.
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MESH Headings
- Aged
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Case-Control Studies
- Centers for Medicare and Medicaid Services, U.S./economics
- Centers for Medicare and Medicaid Services, U.S./standards
- Female
- Florida
- Humans
- Male
- Patient Readmission/economics
- Patient Readmission/statistics & numerical data
- Reimbursement Mechanisms/economics
- Reimbursement Mechanisms/organization & administration
- Risk Adjustment
- United States
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Affiliation(s)
- Benjamin Y. Li
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
| | - Kenneth L. Urish
- Magee Bone and Joint Center, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bruce L. Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chang He
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, University of Michigan, Ann Arbor
| | - Tudor Borza
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
- Department of Urology, University of Wisconsin, Madison
| | - Yongmei Qin
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
| | - Hye Sung Min
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
| | - James M. Dupree
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
| | - Chad Ellimoottil
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
| | - Brent K. Hollenbeck
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
| | - Mariel S. Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor
| | - Jonathan E. Helm
- Operations and Decision Technologies, Indiana University Kelley School of Business, Bloomington
| | - Ted A. Skolarus
- Dow Division for Urologic Health Services Research, Department of Urology, University of Michigan, Ann Arbor
- Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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30
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Borza T, Oreline MK, Skolarus TA, Norton EC, Ryan AM, Ellimoottil C, Dimick JB, Shahinian VB, Hollenbeck BK. Association of the Hospital Readmissions Reduction Program With Surgical Readmissions. JAMA Surg 2019; 153:243-250. [PMID: 29167870 DOI: 10.1001/jamasurg.2017.4585] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Tudor Borza
- Dow Health Services Research Division, Department of Urology, University of Michigan, Ann Arbor
| | - Mary K. Oreline
- Dow Health Services Research Division, Department of Urology, University of Michigan, Ann Arbor
| | - Ted A. Skolarus
- Dow Health Services Research Division, Department of Urology, University of Michigan, Ann Arbor,Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Edward C. Norton
- Department of Health Management and Policy, University of Michigan, Ann Arbor,Department of Economics, University of Michigan, Ann Arbor,National Bureau of Economic Research, Cambridge, Massachusetts
| | - Andrew M. Ryan
- Department of Health Management and Policy, University of Michigan, Ann Arbor,Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
| | - Chad Ellimoottil
- Dow Health Services Research Division, Department of Urology, University of Michigan, Ann Arbor
| | - Justin B. Dimick
- Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor,Surgical Innovation Editor, JAMA Surgery
| | | | - Brent K. Hollenbeck
- Dow Health Services Research Division, Department of Urology, University of Michigan, Ann Arbor
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31
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Kirk PS, Skolarus TA, Jacobs BL, Qin Y, Li B, Sessine M, Liu X, Zhu K, Gilbert SM, Hollenbeck BK, Urish K, Helm J, Lavieri MS, Borza T. Characterising 'bounce-back' readmissions after radical cystectomy. BJU Int 2019; 124:955-961. [PMID: 31313473 DOI: 10.1111/bju.14874] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To examine predictors of early readmissions after radical cystectomy (RC). Factors associated with preventable readmissions may be most evident in readmissions that occur within 3 days of discharge, commonly termed 'bounce-back' readmissions, and identifying such factors may inform efforts to reduce surgical readmissions. PATIENTS AND METHODS We utilised the Healthcare Cost and Utilization Project's State Inpatient Databases to examine 1867 patients undergoing RC in 2009 and 2010, and identified all patients readmitted within 30 days of discharge. We assessed differences between patients experiencing bounce-back readmission compared to those readmitted 8-30 days after discharge using logistic regression models and also calculated abbreviated LACE scores to assess the utility of common readmissions risk stratification algorithms. RESULTS The 30-day and bounce-back readmission rates were 28.4% and 5.6%, respectively. Although no patient or index hospitalisation characteristics were significantly associated with bounce-back readmissions in adjusted analyses, bounce-back patients did have higher rates of gastrointestinal (14.3% vs 6.7%, P = 0.02) and wound (9.5% vs 3.0%, P < 0.01) diagnoses, as well as increased index and readmission length of stay (5 vs 4 days, P = 0.01). Overall, the median abbreviated LACE score was 7, which fell into the moderate readmission risk category, and no difference was observed between readmitted and non-readmitted patients. CONCLUSION One in five readmissions after RC occurs within 3 days of initial discharge, probably due to factors present at discharge. However, sociodemographic and clinical factors, as well as traditional readmission risk tools were not predictive of this bounce-back. Effective strategies to reduce bounce-back readmission must identify actionable clinical factors prior to discharge.
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Affiliation(s)
- Peter S Kirk
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA.,VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yongmei Qin
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Benjamin Li
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michael Sessine
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Xiang Liu
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Kevin Zhu
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Scott M Gilbert
- Department of Genitourinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ken Urish
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jonathan Helm
- Department of Operations and Decision Technologies, Kelley School of Business, Indiana University, Bloomington, IN, USA
| | - Mariel S Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Tudor Borza
- Department of Urology, University of Wisconsin, Madison, WI, USA
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Borza T, Oerline MK, Skolarus TA, Norton EC, Dimick JB, Jacobs BL, Herrel LA, Ellimoottil C, Hollingsworth JM, Ryan AM, Miller DC, Shahinian VB, Hollenbeck BK. Association Between Hospital Participation in Medicare Shared Savings Program Accountable Care Organizations and Readmission Following Major Surgery. Ann Surg 2019; 269:873-878. [PMID: 29557880 PMCID: PMC6146076 DOI: 10.1097/sla.0000000000002737] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the effect of Medicare Shared Savings Program accountable care organizations (ACOs) on hospital readmission after common surgical procedures. SUMMARY BACKGROUND DATA Hospital readmissions following surgery lead to worse patient outcomes and wasteful spending. ACOs, and their associated hospitals, have strong incentives to reduce readmissions from 2 distinct Centers for Medicare and Medicaid Services policies. METHODS We performed a retrospective cohort study using a 20% national Medicare sample to identify beneficiaries undergoing 1 of 7 common surgical procedures-abdominal aortic aneurysm repair, colectomy, cystectomy, prostatectomy, lung resection, total knee arthroplasty, and total hip arthroplasty-between 2010 and 2014. The primary outcome was 30-day risk-adjusted readmission rate. We performed difference-in-differences analyses using multilevel logistic regression models to quantify the effect of hospital ACO affiliation on readmissions following these procedures. RESULTS Patients underwent a procedure at one of 2974 hospitals, of which 389 were ACO affiliated. The 30-day risk-adjusted readmission rate decreased from 8.4% (95% CI, 8.1-8.7%) to 7.0% (95% CI, 6.7-7.3%) for ACO affiliated hospitals (P < 0.001) and from 7.9% (95% CI, 7.8-8.0%) to 7.1% (95% CI, 6.9-7.2%) for non-ACO hospitals (P < 0.001). The difference-in-differences of the 2 trends demonstrated an additional 0.52% (95% CI, 0.97-0.078%) absolute reduction in readmissions at ACO hospitals (P = 0.021), which would translate to 4410 hospitalizations avoided. CONCLUSION Readmissions following common procedures decreased significantly from 2010 to 2014. Hospital affiliation with Shared Savings ACOs was associated with significant additional reductions in readmissions. This emphasis on readmission reduction is 1 mechanism through which ACOs improve value in a surgical population.
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Affiliation(s)
- Tudor Borza
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - Mary K. Oerline
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - Ted A. Skolarus
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Edward C. Norton
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Economics, University of Michigan, Ann Arbor, Michigan
- National Bureau of Economic Research, Cambridge, MA
| | - Justin B. Dimick
- Department of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Bruce L. Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Lindsey A. Herrel
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - Chad Ellimoottil
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - John M. Hollingsworth
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - Andrew M. Ryan
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan
- Department of Economics, University of Michigan, Ann Arbor, Michigan
| | - David C. Miller
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
| | - Vahakn B. Shahinian
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Brent K. Hollenbeck
- Department of Urology, Division of Oncology, University of Michigan, Ann Arbor, Michigan
- Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, Michigan
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Modi PK, Herrel LA, Kaufman SR, Yan P, Borza T, Skolarus TA, Schroeck FR, Hollenbeck BK, Shahinian VB. Urologist Practice Structure and Spending for Prostate Cancer Care. Urology 2019; 130:65-71. [PMID: 31029672 DOI: 10.1016/j.urology.2019.03.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 02/19/2019] [Accepted: 03/08/2019] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To investigate the impact of urologist practice structure on health care spending for men with prostate cancer. We hypothesize that 3 elements of urologist practice structure may influence spending for prostate cancer care: urologist participation within a multispecialty group (MSG), practice size among single specialty urology groups, and intensity-modulated radiation therapy (IMRT) ownership. MATERIALS AND METHODS We used a 20% sample of fee-for-service Medicare beneficiaries to identify men newly diagnosed with prostate cancer between 2011 and 2014. We identified each man's urologist and used data from the Healthcare Relational Spheres provider files to identify practice type, size, and IMRT ownership for each urologist. We then fit generalized linear mixed models to estimate the association between these practice features and Medicare payments in the year after diagnosis. All models were adjusted for patient and healthcare market characteristics. RESULTS We identified 35,929 men with newly diagnosed prostate cancer who were treated by 6381 urologists. Medicare payments for men with newly diagnosed prostate cancer were significantly lower in MSGs ($19,181 v. $22,366 large single specialty group, P < 0.001) and significantly higher among practices with IMRT ownership ($23,801 v. $20,162 for non-owners, P < 0.001). These differences persisted in sensitivity analyses including only men treated with radiotherapy and examining only prostate cancer-related claims. CONCLUSION Urologist practice structure is associated with payments for prostate cancer care. MSGs had the lowest Medicare payments per episode of prostate cancer care while groups with IMRT ownership had the highest.
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Affiliation(s)
- Parth K Modi
- Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Lindsey A Herrel
- Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Samuel R Kaufman
- Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Phyllis Yan
- Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Tudor Borza
- Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Ted A Skolarus
- Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Florian R Schroeck
- Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, NH
| | - Brent K Hollenbeck
- Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
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Modi PK, Kaufman SR, Borza T, Oliphant BW, Ryan AM, Miller DC, Shahinian VB, Ellimoottil C, Hollenbeck BK. Medicare Accountable Care Organizations and Use of Potentially Low-Value Procedures. Surg Innov 2018; 26:227-233. [PMID: 30497340 DOI: 10.1177/1553350618816594] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate the effect of Accountable Care Organizations (ACOs) on the use of vertebroplasty and arthroscopic partial meniscectomy, 2 procedures for which randomized controlled trials suggest similar outcomes to sham surgery and therefore may provide low value. Medicare Shared Savings Program ACOs aim to improve quality and decrease health care spending. Reducing the use of potentially low-value procedures can accomplish both of these goals. METHODS We performed a retrospective cohort study of patients who underwent potentially low-value orthopedic procedures (vertebroplasty and partial meniscectomy) and a control (hip fracture) from 2010 to 2015 using a 20% sample of national Medicare claims. We performed an interrupted time-series analysis using linear spline models to evaluate the count of each procedure per 1000 patients, stratified by ACO participation. RESULTS We identified 76 256 patients who underwent arthroscopic partial meniscectomy, 44 539 patients who underwent vertebroplasty, and 50 760 patients who underwent hip fracture admission. Arthroscopic partial meniscectomy rates decreased, vertebroplasty rates remained stable, and hip fracture rates increased for both groups during the study period, with similar trends among ACO and non-ACO patients. After January 1, 2013, ACO and non-ACO populations had similar trends for vertebroplasty (ACO incidence rate ratio [IRR] = 1.15 [1.08-1.23] vs non-ACO IRR = 1.11 [1.05-1.16]), meniscectomy (ACO IRR = 1.06 [1.01-1.12] vs non-ACO IRR = 1.03 [0.99-1.07]), and hip fracture (ACO IRR = 1.08 [1.01-1.14] vs non-ACO IRR = 1.08 [1.03-1.13]). CONCLUSIONS ACOs were not associated with a reduction in the frequency of vertebroplasty and arthroscopic partial meniscectomy.
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Affiliation(s)
| | | | - Tudor Borza
- 1 University of Michigan, Ann Arbor, MI, USA
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Modi PK, Hollenbeck BK, Borza T. Searching for the value of accountable care organizations in cancer care. Cancer 2018; 124:4287-4289. [PMID: 30419155 DOI: 10.1002/cncr.31698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/15/2018] [Accepted: 06/18/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Parth K Modi
- Division of Urologic Oncology, Department of Urology, Michigan Medicine, Ann Arbor, Michigan
| | - Brent K Hollenbeck
- Division of Urologic Oncology, Department of Urology, Michigan Medicine, Ann Arbor, Michigan
| | - Tudor Borza
- Department of Urology, University of Wisconsin, Madison, Wisconsin
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Shukla PS, Borza T, Critchley AT, Hiltz D, Norrie J, Prithiviraj B. Ascophyllum nodosum extract mitigates salinity stress in Arabidopsis thaliana by modulating the expression of miRNA involved in stress tolerance and nutrient acquisition. PLoS One 2018; 13:e0206221. [PMID: 30372454 PMCID: PMC6205635 DOI: 10.1371/journal.pone.0206221] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 10/09/2018] [Indexed: 11/25/2022] Open
Abstract
Ascophyllum nodosum extract (ANE) contains bioactive compounds that improve the growth of Arabidopsis in experimentally-induced saline conditions; however, the molecular mechanisms through which ANE elicits tolerance to salinity remain largely unexplored. Micro RNAs (miRNAs) are key regulators of gene expression, playing crucial roles in plant growth, development, and stress tolerance. Next generation sequencing of miRNAs from leaves of control Arabidopsis and from plants subjected to three treatments (ANE, NaCl and ANE+NaCl) was used to identify ANE-responsive miRNA in the absence and presence of saline conditions. Differential gene expression analysis revealed that ANE had a strong effect on miRNAs expression in both conditions. In the presence of salinity, ANE tended to reduce the up-regulation or the down-regulation trend induced caused by NaCl in miRNAs such as ath-miR396a-5p, ath-miR399, ath-miR2111b and ath-miR827. To further uncover the effects of ANE, the expression of several target genes of a number of ANE-responsive miRNAs was analyzed by qPCR. NaCl, but not ANE, down-regulated miR396a-5p, which negatively regulated the expression of AtGRF7 leading to a higher expression of AtDREB2a and AtRD29 in the presence of ANE+NaCl, as compared to ANE alone. ANE+NaCl initially reduced and then enhanced the expression of ath-miR169g-5p, while the expression of the target genes AtNFYA1 and ATNFYA2, known to be involved in the salinity tolerance mechanism, was increased as compared to ANE or to NaCl treatments. ANE and ANE+NaCl modified the expression of ath-miR399, ath-miR827, ath-miR2111b, and their target genes AtUBC24, AtWAK2, AtSYG1 and At3g27150, suggesting a role of ANE in phosphate homeostasis. In vivo and in vitro experiments confirmed the improved growth of Arabidopsis in presence of ANE, in saline conditions and in phosphate-deprived medium, further substantiating the influence of ANE on a variety of essential physiological processes in Arabidopsis including salinity tolerance and phosphate uptake.
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Affiliation(s)
- Pushp Sheel Shukla
- Marine Bio-products Research Laboratory, Dalhousie University, Department of Plant, Food and Environmental Sciences, Truro, Nova Scotia, Canada
| | - Tudor Borza
- Marine Bio-products Research Laboratory, Dalhousie University, Department of Plant, Food and Environmental Sciences, Truro, Nova Scotia, Canada
| | - Alan T. Critchley
- Research and Development, Acadian Seaplants Limited, Dartmouth, Nova Scotia, Canada
| | - David Hiltz
- Research and Development, Acadian Seaplants Limited, Dartmouth, Nova Scotia, Canada
| | - Jeff Norrie
- Research and Development, Acadian Seaplants Limited, Dartmouth, Nova Scotia, Canada
| | - Balakrishnan Prithiviraj
- Marine Bio-products Research Laboratory, Dalhousie University, Department of Plant, Food and Environmental Sciences, Truro, Nova Scotia, Canada
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Lee AJ, Liu X, Borza T, Qin Y, Li BY, Urish KL, Kirk PS, Gilbert S, Hollenbeck BK, Helm JE, Lavieri MS, Skolarus TA, Jacobs BL. Role of Post-Acute Care on Hospital Readmission After High-Risk Surgery. J Surg Res 2018; 234:116-122. [PMID: 30527462 DOI: 10.1016/j.jss.2018.08.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [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: 01/25/2018] [Revised: 07/31/2018] [Accepted: 08/24/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Payment models, including the Hospital Readmissions Reduction Program and bundled payments, place pressures on hospitals to limit readmissions. Against this backdrop, we sought to investigate the association of post-acute care after major surgery and readmission rates. METHODS We identified patients undergoing high-risk surgery (abdominal aortic aneurysm repair, coronary bypass grafting, aortic valve replacement, carotid endarterectomy, esophagectomy, pancreatectomy, lung resection, and cystectomy) from 2005 to 2010 using the Healthcare Cost and Utilization Project's State Inpatient Database. The primary outcome was readmission rates after major surgery. Secondary outcome was readmission length of stay. RESULTS We identified 135,523 patients of whom 56,720 (42%) received post-acute care. Patients receiving post-acute care had higher readmission rates than those who were discharged home (16% versus 10%, respectively; P < 0.001). The risk-adjusted readmission length of stay was greatest for patients who received care from a skilled nursing facility, followed by those who received home care, and lowest for those who did not receive post-acute care (7.1 versus 5.4 versus 4.8 d, respectively; P < 0.001). CONCLUSIONS The use of post-acute care was associated with higher readmission rates and higher readmission lengths of stay. Improving the support of patients in post-acute care settings may help reduce readmissions and readmission intensity.
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Affiliation(s)
- Austin J Lee
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Xiang Liu
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - Tudor Borza
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan; Divisions of Health Services Research and Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Yongmei Qin
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Benjamin Y Li
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Kenneth L Urish
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Peter S Kirk
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Scott Gilbert
- Department of Urology, H. Lee Moffitt Cancer Center, Tampa, Florida
| | - Brent K Hollenbeck
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan; Divisions of Health Services Research and Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Jonathan E Helm
- W.P. Carey School of Business, Arizona State University, Tempe, Arizona
| | - Mariel S Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, Michigan
| | - Ted A Skolarus
- Divisions of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan; Divisions of Health Services Research and Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Tempe, Arizona
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Li BY, Zhu KY, Urish KL, Jacobs BL, Qin Y, Borza T, Hollenbeck BK, Helm JE, Lavieri MS, Skolarus TA. Understanding Readmission Policy Implications for US Hospitals Performing Major Surgery. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Walker LR, Engle TB, Vu H, Tosky ER, Nonneman DJ, Smith TPL, Borza T, Burkey TE, Plastow GS, Kachman SD, Ciobanu DC. Synaptogyrin-2 influences replication of Porcine circovirus 2. PLoS Genet 2018; 14:e1007750. [PMID: 30379811 PMCID: PMC6245838 DOI: 10.1371/journal.pgen.1007750] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 11/20/2018] [Accepted: 10/09/2018] [Indexed: 11/19/2022] Open
Abstract
Porcine circovirus 2 (PCV2) is a circular single-stranded DNA virus responsible for a group of diseases collectively known as PCV2 Associated Diseases (PCVAD). Variation in the incidence and severity of PCVAD exists between pigs suggesting a host genetic component involved in pathogenesis. A large-scale genome-wide association study of experimentally infected pigs (n = 974), provided evidence of a host genetic role in PCV2 viremia, immune response and growth during challenge. Host genotype explained 64% of the phenotypic variation for overall viral load, with two major Quantitative Trait Loci (QTL) identified on chromosome 7 (SSC7) near the swine leukocyte antigen complex class II locus and on the proximal end of chromosome 12 (SSC12). The SNP having the strongest association, ALGA0110477 (SSC12), explained 9.3% of the genetic and 6.2% of the phenotypic variance for viral load. Dissection of the SSC12 QTL based on gene annotation, genomic and RNA-sequencing, suggested that a missense mutation in the SYNGR2 (SYNGR2 p.Arg63Cys) gene is potentially responsible for the variation in viremia. This polymorphism, located within a protein domain conserved across mammals, results in an amino acid variant SYNGR2 p.63Cys only observed in swine. PCV2 titer in PK15 cells decreased when the expression of SYNGR2 was silenced by specific-siRNA, indicating a role of SYNGR2 in viral replication. Additionally, a PK15 edited clone generated by CRISPR-Cas9, carrying a partial deletion of the second exon that harbors a key domain and the SYNGR2 p.Arg63Cys, was associated with a lower viral titer compared to wildtype PK15 cells (>24 hpi) and supernatant (>48hpi)(P < 0.05). Identification of a non-conservative substitution in this key domain of SYNGR2 suggests that the SYNGR2 p.Arg63Cys variant may underlie the observed genetic effect on viral load.
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Affiliation(s)
- Lianna R. Walker
- Animal Science Department, University of Nebraska, Lincoln, Nebraska, United States of America
| | - Taylor B. Engle
- Animal Science Department, University of Nebraska, Lincoln, Nebraska, United States of America
| | - Hiep Vu
- Animal Science Department, University of Nebraska, Lincoln, Nebraska, United States of America
| | - Emily R. Tosky
- Animal Science Department, University of Nebraska, Lincoln, Nebraska, United States of America
| | - Dan J. Nonneman
- USDA, ARS, U.S. Meat Animal Research Center, Clay Center, Nebraska, United States of America
| | - Timothy P. L. Smith
- USDA, ARS, U.S. Meat Animal Research Center, Clay Center, Nebraska, United States of America
| | - Tudor Borza
- Department of Plant, Food and Environmental Sciences, Faculty of Agriculture, Dalhousie University, Truro, Canada
| | - Thomas E. Burkey
- Animal Science Department, University of Nebraska, Lincoln, Nebraska, United States of America
| | - Graham S. Plastow
- Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, Canada
| | - Stephen D. Kachman
- Department of Statistics, University of Nebraska, Lincoln, Nebraska, United States of America
| | - Daniel C. Ciobanu
- Animal Science Department, University of Nebraska, Lincoln, Nebraska, United States of America
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Kirk PS, Borza T, Caram MEV, Shumway DA, Makarov DV, Burns JA, Shelton JB, Leppert JT, Chapman C, Chang M, Hollenbeck BK, Skolarus TA. Characterising potential bone scan overuse amongst men treated with radical prostatectomy. BJU Int 2018; 124:55-61. [PMID: 30246937 DOI: 10.1111/bju.14551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To characterise bone scan use, and potential overuse, after radical prostatectomy (RP) using data from a large, national integrated delivery system. Overuse of imaging is well documented in the setting of newly diagnosed prostate cancer, but whether overuse persists after RP remains unknown. PATIENTS AND METHODS We identified 12 269 patients with prostate cancer treated with RP between 2005 and 2008 using the Veterans Administration Central Cancer Registry. We used administrative and laboratory data to examine rates of bone scan use, including preceding prostate-specific antigen (PSA) levels, and receipt of adjuvant or salvage therapy. We then performed multivariable logistic regression to identify factors associated with post-RP bone scan use. RESULTS At a median follow-up of 6.8 years, one in five men (22%) underwent a post-RP bone scan at a median PSA level of 0.2 ng/mL. Half of bone scans (48%) were obtained in men who did not receive further treatment with androgen-deprivation or radiation therapy. After adjustment, post-RP bone scan was associated with a prior bone scan (adjusted odds ratio [aOR] 1.55, 95% confidence interval [CI] 1.32-1.84), positive surgical margin (aOR 1.68, 95% CI 1.40-2.01), preoperative PSA level (aOR 1.02, 95% CI 1.01-1.03), as well as Hispanic ethnicity, Black race, and increasing D'Amico risk category, but not with age or comorbidity. CONCLUSION We found a substantial rate of bone scan utilisation after RP. The majority were performed for PSA levels of <1 ng/mL where the likelihood of a positive test is low. More judicious use of imaging appears warranted in the post-RP setting.
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Affiliation(s)
- Peter S Kirk
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Tudor Borza
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Megan E V Caram
- Division of Hematology and Oncology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA.,VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Dean A Shumway
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Danil V Makarov
- Departments of Urology and Population Health, NYU Langone Medical Center, New York, NY, USA.,Veterans Affairs (VA) New York Healthcare System, New York, NY, USA
| | - Jennifer A Burns
- VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | | | - John T Leppert
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA.,VA Palo Alto Healthcare System, Palo Alto, CA, USA
| | - Christina Chapman
- VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Michael Chang
- Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System, Ann Arbor, MI, USA.,VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Krishnan N, Li B, Jacobs BL, Ambani SN, Borza T, He C, Hollenbeck BK, Morgan T, Hafez KS, Weizer AZ, Montgomery JS, Lee CT, Lesse O, Lavieri MS, Helm JE, Skolarus TA. The Fate of Radical Cystectomy Patients after Hospital Discharge: Understanding the Black Box of the Pre-readmission Interval. Eur Urol Focus 2018; 4:711-717. [DOI: 10.1016/j.euf.2016.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 07/12/2016] [Indexed: 11/25/2022]
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Kirk PS, Borza T, Dupree JM, Wei JT, Ellimoottil C, Caram MEV, Burkhardt M, Heidelbaugh JJ, Hollenbeck BK, Skolarus TA. Potential Savings in Medicare Part D for Common Urological Conditions. Urol Pract 2018; 5:351-359. [PMID: 30555855 DOI: 10.1016/j.urpr.2017.07.004] [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] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction Millions of patients take prescription medications each year for common urological conditions. Generic and brand-name drugs have widely divergent pricing despite similar therapeutic benefit and side effect profiles. We examined prescribing patterns across provider types for generic and brand-name drugs used to treat 3 common urological conditions, and estimated economic implications for Medicare Part D spending. Methods We extracted 2014 prescription claims and payments from Medicare Part D and categorized oral medications used to treat 3 urological conditions, namely benign prostatic hyperplasia, erectile dysfunction and overactive bladder. We examined claims and payments for each medication among urologists and nonurologists. Lastly, we estimated potential savings by selecting a low cost or generic drug as a cost comparator for each class. Results There were significant differences in prescribing patterns across these conditions, with urologists prescribing more brand-name and expensive medications (p <0.001). The total potential savings related to prescriptions of more expensive and nongeneric drugs in 2014 was $1 billion (benign prostatic hyperplasia $348,454,910, erectile dysfunction $10,211,914 and overactive bladder $698,130,833). These potential savings comprised 53% of the total spending for these medications in 2014. Conclusions Within Medicare Part D the potential savings associated with generic substitution for higher cost and nongeneric drugs for 3 common urological conditions surpassed $1 billion, with urologists more likely to prescribe brand-name and more expensive drugs. Increasing low cost and generic drug use where available evidence of efficacy is equivocal represents a promising policy target to optimize prescription drug spending.
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Affiliation(s)
- Peter S Kirk
- Dow Division of Health Services Research, Department of Urology, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Tudor Borza
- Dow Division of Health Services Research, Department of Urology, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - James M Dupree
- Dow Division of Health Services Research, Department of Urology, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - John T Wei
- Dow Division of Health Services Research, Department of Urology, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Chad Ellimoottil
- Dow Division of Health Services Research, Department of Urology, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Megan E V Caram
- Division of Hematology & Oncology, Department of Internal Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Mary Burkhardt
- University of Michigan Health System, Pharmacy Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Joel J Heidelbaugh
- Department of Family Medicine, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Brent K Hollenbeck
- Dow Division of Health Services Research, Department of Urology, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Ted A Skolarus
- Dow Division of Health Services Research, Department of Urology VA Ann Arbor Healthcare System, Ann Arbor, Michigan, VA Health Services Research & Development Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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Urish KL, Qin Y, Li BY, Borza T, Sessine M, Kirk P, Hollenbeck BK, Helm JE, Lavieri MS, Skolarus TA, Jacobs BL. Predictors and Cost of Readmission in Total Knee Arthroplasty. J Arthroplasty 2018; 33:2759-2763. [PMID: 29753618 PMCID: PMC6103832 DOI: 10.1016/j.arth.2018.04.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/25/2018] [Accepted: 04/02/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Comprehensive Care for Joint Replacement bundle was created to decrease total knee arthroplasty (TKA) cost. To help accomplish this, there is a focus on reducing TKA readmissions. However, there is a lack of national representative sample of all-payer hospital admissions to direct strategy, identify risk factors for readmission, and understand actual readmission cost. METHODS We used the Nationwide Readmission Database to examine national readmission rates, predictors of readmission, and associated readmission costs for elective TKA procedures. We fit a multivariable logistic regression model to examine factors associated with readmission. Then, we determined mean readmission costs and calculated the readmission cost when distributed across the entire TKA population. RESULTS We identified 224,465 patients having TKA across all states participating in the Nationwide Readmission Database. The mean unadjusted 30-day TKA readmission rate was 4%. The greatest predictors of readmission were congestive heart failure (odds ratio [OR] 2.51, 95% confidence interval [CI] 2.62-2.80), renal disease (OR 2.19, 95% CI 2.03-2.37), and length of stay greater than 4 days (OR 2.4, 95% CI 2.25-2.61). The overall median cost for each readmission was $6753 ± 175. Extrapolating the readmission cost for the entire TKA population resulted in the readmission cost being 2% of the overall 30-day procedure cost. CONCLUSIONS A major focus of the Comprehensive Care for Joint Replacement bundle is improving cost and quality by limiting readmission rates. TKA readmissions are low and comprise a small percentage of total TKA cost, suggesting that they may not be the optimal measure of quality care or a significant driver of overall cost.
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Affiliation(s)
- Kenneth L. Urish
- Arthritis and Arthroplasty Design Group, The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center; Department of Orthopaedic Surgery, Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh; Department of Biomedical Engineering, Carnegie Mellon University, 300 Halket Street, Suite 1601, Pittsburgh, PA 15232
| | - Yongmei Qin
- Department of Urology, Division of Oncology; Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI
| | - Benjamin Y. Li
- Department of Urology, Division of Oncology, MI; Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor
| | - Tudor Borza
- Department of Urology, Division of Oncology; Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI
| | - Michael Sessine
- Department of Urology, Division of Oncology; Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI
| | - Peter Kirk
- Department of Urology, Division of Oncology; Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI
| | - Brent K. Hollenbeck
- Department of Urology, Division of Oncology; Dow Division for Urologic Health Service Research, University of Michigan, Ann Arbor, MI
| | - Jonathan E. Helm
- Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Mariel S. Lavieri
- Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI
| | - Ted A. Skolarus
- Department of Urology, Division of Oncology; Dow Division for Urologic Health Service Research, Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, University of Michigan, Ann Arbor, MI
| | - Bruce L. Jacobs
- Department of Urology, University of Pittsburgh, Pittsburgh, PA
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Modi PK, Kaufman SR, Borza T, Yan P, Miller DC, Skolarus TA, Hollingsworth JM, Norton EC, Shahinian VB, Hollenbeck BK. Variation in prostate cancer treatment and spending among Medicare shared savings program accountable care organizations. Cancer 2018; 124:3364-3371. [PMID: 29905943 DOI: 10.1002/cncr.31573] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 04/27/2018] [Accepted: 05/03/2018] [Indexed: 11/12/2022]
Abstract
BACKGROUND Accountable care organizations (ACOs) have been shown to reduce prostate cancer treatment among men unlikely to benefit because of competing risks (ie, potential overtreatment). This study assessed whether the level of engagement in ACOs by urologists affected rates of treatment, overtreatment, and spending. METHODS A 20% sample of national Medicare data was used to identify men diagnosed with prostate cancer between 2012 and 2014. The extent of urologist engagement in an ACO, as measured by the proportion of patients in an ACO managed by an ACO-participating urologist, served as the exposure. The use of treatment, potential overtreatment (ie, treatment in men with a ≥75% risk of 10-year noncancer mortality), and average payments in the year after diagnosis for each ACO were modeled. RESULTS Among 2822 men with newly diagnosed prostate cancer, the median rates of treatment and potential overtreatment by an ACO were 71.3% (range, 23.6%-79.5%) and 53.6% (range, 12.4%-76.9%), respectively. Average Medicare payments among ACOs in the year after diagnosis ranged from $16,523.52 to $34,766.33. Stronger urologist-ACO engagement was not associated with treatment (odds ratio, 0.87; 95% confidence interval, 0.6-1.2; P = .4) or spending (9.7% decrease in spending; P = .08). However, urologist engagement was associated with a lower likelihood of potential overtreatment (odds ratio, 0.29; 95% confidence interval, 0.1-0.86; P = .03). CONCLUSIONS ACOs vary widely in treatment, potential overtreatment, and spending for prostate cancer. ACOs with stronger urologist engagement are less likely to treat men with a high risk of noncancer mortality, and this suggests that organizations that better engage specialists may be able to improve the value of specialty care. Cancer 2018. © 2018 American Cancer Society.
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Affiliation(s)
- Parth K Modi
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Samuel R Kaufman
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Tudor Borza
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Phyllis Yan
- Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - David C Miller
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Ted A Skolarus
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - John M Hollingsworth
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - Edward C Norton
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan.,Department of Economics, University of Michigan, Ann Arbor, Michigan.,National Bureau of Economic Research, Cambridge, Massachusetts
| | - Vahakn B Shahinian
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Brent K Hollenbeck
- Division of Oncology, Department of Urology, University of Michigan, Ann Arbor, Michigan.,Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor, Michigan
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Affiliation(s)
- Amy N Luckenbaugh
- Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
| | - Tudor Borza
- Dow Division for Health Services Research, Department of Urology, University of Michigan, Ann Arbor, MI
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Sessine M, Borza T, Weizer A, Kirk P, Liu X, Li B, Hollenbeck B, Qin Y, Jacobs B, Urish K, Helm J, Lavieri M, Skolarus T. MP71-02 REFRAMING READMISSION REDUCTION INCENTIVES AFTER RADICAL CYSTECTOMY. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.2266] [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: 11/17/2022]
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Fam M, Yabes J, Hale N, Turner R, Bandari J, Macleod L, Hugar L, Gingrich J, Borza T, Skolarus T, Davies B, Jacobs B. MP71-20 COMPARATIVE EFFECTIVENESS OF NEOADJUVANT AND ADJUVANT CHEMOTHERAPY IN THE MEDICARE BLADDER CANCER POPULATION. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.2284] [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: 11/28/2022]
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Kirk PS, Borza T, Shahinian VB, Caram ME, Makarov DV, Shelton JB, Leppert JT, Blake RM, Davis JA, Hollenbeck BK, Sales A, Skolarus TA. The implications of baseline bone-health assessment at initiation of androgen-deprivation therapy for prostate cancer. BJU Int 2018; 121:558-564. [PMID: 29124881 PMCID: PMC5878705 DOI: 10.1111/bju.14075] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To assess bone-density testing (BDT) use amongst prostate cancer survivors receiving androgen-deprivation therapy (ADT), and downstream implications for osteoporosis and fracture diagnoses, as well as pharmacological osteoporosis treatment in a national integrated delivery system. PATIENTS AND METHODS We identified 17 017 men with prostate cancer who received any ADT between 2005 and 2014 using the Veterans Health Administration cancer registry and administrative data. We identified claims for BDT within a 3-year period of ADT initiation. We then used multivariable regression to examine the association between BDT use and incident osteoporosis, fracture, and use of pharmacological treatment. RESULTS We found that a minority of patients received BDT (n = 2 502, 15%); however, the rate of testing increased to >20% by the end of the study period. Men receiving BDT were older at diagnosis and had higher-risk prostate cancer (both P < 0.001). Osteoporosis and fracture diagnoses, use of vitamin D ± calcium, and bisphosphonates were all more common in men who received BDT. After adjustment, BDT, and to a lesser degree ≥2 years of ADT, were both independently associated with incident osteoporosis, fracture, and osteoporosis treatment. CONCLUSIONS BDT is rare amongst patients with prostate cancer treated with ADT in this integrated delivery system. However, BDT was associated with substantially increased treatment of osteoporosis indicating an underappreciated burden of osteoporosis amongst prostate cancer survivors initiating ADT. Optimising BDT use and osteoporosis management in this at-risk population appears warranted.
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Affiliation(s)
- Peter S. Kirk
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System
| | - Tudor Borza
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System
| | - Vahakn B. Shahinian
- Division of Nephrology, Department of Internal Medicine, University of Michigan Health System
| | - Megan E.V. Caram
- Division of Hematology & Oncology, Department of Internal Medicine, University of Michigan Health System
- VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System
| | - Danil V. Makarov
- Departments of Urology and Population Health, NYU Langone Medical Center
- VA New York Healthcare System, NY
| | | | - John T. Leppert
- Department of Urology, Stanford University School of Medicine
- VA Palo Alto Healthcare System, Palo Alto
| | - Ryan M. Blake
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System
| | - Jennifer A. Davis
- VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System
| | - Brent K. Hollenbeck
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System
| | - Anne Sales
- VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System
- Department of Learning Health Sciences, University of Michigan Medical School
| | - Ted A. Skolarus
- Dow Division of Health Services Research, Department of Urology, University of Michigan Health System
- VA Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System
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Borza T, Yan P, Kaufman SR, Herrel L, Skolarus TA, Shahinian VB, Hollenbeck B. PD52-01 ASSOCIATION BETWEEN RADIATION FACILITY OWNERSHIP AND VARIATION IN PROSTATE CANCER TREATMENT AND SPENDING. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.2353] [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: 10/17/2022]
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50
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Fam M, Yabes J, Hale N, Turner R, Yu M, Macleod L, Hugar L, Gingrich J, Borza T, Skolarus T, Davies B, Jacobs B. MP44-02 CHANGING TRENDS IN THE USE OF CHEMOTHERAPY FOR MUSCLE-INVASIVE BLADDER CANCER IN THE UNITED STATES. J Urol 2018. [DOI: 10.1016/j.juro.2018.02.1421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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