The Impact of Diaphorina citri-Vectored 'Candidatus Liberibacter asiaticus' on Citrus Metabolism.

'Candidatus Liberibacter asiaticus' is associated with the devastating citrus disease Huanglongbing (HLB). It is transmitted by grafting infected material to healthy plants and by the feeding of the Asian citrus psyllid (Diaphorina citri). Previously, we demonstrated that a metabolomics approach using proton-nuclear magnetic resonance spectroscopy discriminates healthy from diseased plants via grafting. This work assessed the capability of this technology in discriminating healthy and diseased plants when the bacterium is vectored by psyllids. One-year-old greenhouse-grown 'Lisbon' lemon trees were exposed to either carrier psyllids (exposed, n = 10), or psyllids that were free of 'Candidatus Liberibacter asiaticus' (control, n = 6). Leaf metabolites were tracked for 1 year and disease diagnosis was made using quantitative PCR. Overall, 31 water-soluble metabolites were quantified in leaves, including four sugars and 12 amino acids. Analysis via nonmetric multidimensional scaling and principal component analysis revealed significant differences between the leaf metabolome of control versus infected trees beginning at 8 weeks postexposure, including alterations in glucose and quinic acid concentrations. These findings provide a longitudinal overview of the metabolic effects of HLB during the early phases of disease, and confirm previous experimental work demonstrating that infection elicits changes in the leaf metabolome that enables discrimination between healthy and infected plants. Here we demonstrate that the mode of inoculation (i.e., graft versus psyllid) results in a similar pathology.

An Improved Recombinase Polymerase Amplification Coupled with Lateral Flow Assay for Rapid Field Detection of 'Candidatus Liberibacter asiaticus'.

Huanglongbing (HLB) is a destructive citrus disease that affects citrus production worldwide. 'Candidatus Liberibacter asiaticus' (CLas), a phloem-limited bacterium, is the associated causal agent of HLB. The current standard for detection of CLas is real-time quantitative polymerase chain reaction (qPCR) using either the CLas 16S rRNA gene or the ribonucleotide reductase (RNR) gene-specific primers/probe. qPCR requires well-equipped laboratories and trained personnel, which is not convenient for rapid field detection of CLas-infected trees. Recombinase polymerase amplification (RPA) assay is a fast, portable alternative to PCR-based diagnostic methods. In this study, an RPA assay was developed to detect CLas in crude citrus extracts utilizing isothermal amplification, without the need for DNA purification. Primers were designed to amplify a region of the CLas RNR gene, and a fluorescent labeled probe allowed for detection of the amplicon in real-time within 8 mins at 39°C. The assay was specific to CLas, and the sensitivity was comparable to qPCR, with a detection limit cycle threshold of 34. Additionally, the RPA assay was combined with a lateral flow device for a point-of-use assay that is field deployable. Both assays were 100% accurate in detecting CLas in fresh citrus crude extracts from leaf midribs and roots from five California strains of CLas tested in the Contained Research Facility in Davis, California. This assay will be important for distinguishing CLas-infected trees in California from those infected by other pathogens that cause similar disease symptoms and can help control HLB spread.

Racial Disparities in Prostate Specific Antigen Screening and Referral to Urology in a Large, Integrated Health Care System: A Retrospective Cohort Study.

PURPOSE: Contemporary trends and racial disparities in prostate cancer screening and referral to urology for prostate cancer risk are not well characterized, despite consensus that Black men are at higher risk for poor prostate cancer outcomes. The objective of this study was to characterize current racial disparities in prostate cancer screening and referral from primary care to urology for prostate cancer concern within our large, integrated health care system. MATERIALS AND METHODS: This retrospective cohort study used data from Atrium Health's enterprise data warehouse, which includes patient information from more than 900 care locations across North Carolina, South Carolina and Georgia. We included all men seen in the ambulatory or outpatient setting between 2014 and 2019 who were ≥40 years old. Clinical and demographic data were collected for all men, including age and race. Racial outcomes were reported for all groups with >2% representation in the population. Between-group comparisons were determined using chi-squared analysis, Wilcoxon rank sum testing and multivariable logistic regression, with significance defined as p <0.05. RESULTS: We observed a significant decrease in prostate specific antigen testing across all age and racial groups in a cohort of 606,985 men at Atrium Health, including 87,189 Black men, with an overall relative decline of 56%. As compared to White men, Black men were more likely to undergo prostate specific antigen testing (adjusted OR 1.24, 95% CI 1.22-1.26) and be referred to urology for prostate cancer (adjusted OR 1.94, 95% CI 1.75-2.16). CONCLUSIONS: There was a continued significant decline in prostate cancer screening between 2014 and 2019. Despite having modestly elevated odds of being screened for prostate cancer compared to White men, Black men are relatively underscreened when considering that those who undergo prostate specific antigen screening are more likely to be referred by primary care to urology for additional prostate cancer diagnostic evaluation.

Longitudinal Transcriptomic, Proteomic, and Metabolomic Analysis of Citrus limon Response to Graft Inoculation by Candidatus Liberibacter asiaticus.

Presymptomatic detection of citrus trees infected with Candidatus Liberibacter asiaticus (CLas), the bacterial pathogen associated with Huanglongbing (HLB; citrus greening disease), is critical to controlling the spread of the disease. To test whether infected citrus trees produce systemic signals that may be used for indirect disease detection, lemon (Citrus limon) plants were graft-inoculated with either CLas-infected or control (CLas-) budwood, and leaf samples were longitudinally collected over 46 weeks and analyzed for plant changes associated with CLas infection. RNA, protein, and metabolite samples extracted from leaves were analyzed using RNA-Seq, mass spectrometry, and 1H NMR spectroscopy, respectively. Significant differences in specific transcripts, proteins, and metabolites were observed between CLas-infected and control plants as early as 2 weeks post graft (wpg). The most dramatic differences between the transcriptome and proteome of CLas-infected and control plants were observed at 10 wpg, including coordinated increases in transcripts and proteins of citrus orthologs of known plant defense genes. This integrated approach to quantifying plant molecular changes in leaves of CLas-infected plants supports the development of diagnostic technology for presymptomatic or early disease detection as part of efforts to control the spread of HLB into uninfected citrus groves.

Longitudinal Transcriptomic, Proteomic, and Metabolomic Analyses of Citrus sinensis (L.) Osbeck Graft-Inoculated with "Candidatus Liberibacter asiaticus".

"Candidatus Liberibacter asiaticus" (CLas) is the bacterium associated with the citrus disease Huanglongbing (HLB). Current CLas detection methods are unreliable during presymptomatic infection, and understanding CLas pathogenicity to help develop new detection techniques is challenging because CLas has yet to be isolated in pure culture. To understand how CLas affects citrus metabolism and whether infected plants produce systemic signals that can be used to develop improved detection techniques, leaves from Washington Navel orange (Citrus sinensis (L.) Osbeck) plants were graft-inoculated with CLas and longitudinally studied using transcriptomics (RNA sequencing), proteomics (liquid chromatography-tandem mass spectrometry), and metabolomics (proton nuclear magnetic resonance). Photosynthesis gene expression and protein levels were lower in infected plants compared to controls during late infection, and lower levels of photosynthesis proteins were identified as early as 8 weeks post-grafting. These changes coordinated with higher sugar concentrations, which have been shown to accumulate during HLB. Cell wall modification and degradation gene expression and proteins were higher in infected plants during late infection. Changes in gene expression and proteins related to plant defense were observed in infected plants as early as 8 weeks post-grafting. These results reveal coordinated changes in greenhouse navel leaves during CLas infection at the transcript, protein, and metabolite levels, which can inform of biomarkers of early infection.

Caring for Children with Special Health Care Needs: Profiling Pediatricians and Their Health Care Resources.

Background and Objectives Pediatricians face numerous challenges in providing care for children with special health care needs (CSHCN). Few studies have described health care resources available to support pediatricians to care for CSHCN. This study investigated available resources to care for CSHCN and factors associated with having a greater proportion of CSHCN in practice. Methods We conducted a statewide survey of active members of the American Academy of Pediatrics in California to study pediatric subspecialty care access, community and office resources and practice barriers. We performed a logistic regression model on having an "above average proportion" of CSHCN in practice, adjusting for demographics, practice type (rural vs. suburban/urban) and medical resources, care satisfaction, and ease of subspecialty access. Results Our response rate was 50.2% (n = 1290); 75% of respondents reported providing some primary care services, with many primary care pediatricians caring for a high proportion of CSHCN. Pediatricians reported an average of 28% CSHCN in their practices. Rural pediatricians lacked subspecialty access (10-59% reporting no access to the various subspecialties). Factors relating to higher CSHCN in practice included being in academic medical centers and satisfaction in caring for CSHCN. Conclusions Pediatricians report lack of access to mental health services, care coordination and case management. Academic medical centers and higher physician satisfaction in care delivery for CSHCN are associated with more CSHCN in practice. Promoting ways to support pediatricians, such as practice collaboration with behavioral specialists, may be necessary to encourage primary care pediatricians to provide medical homes for CSHCN.

Concurrent Validity of Wearable Activity Trackers Under Free-Living Conditions.

Brooke, SM, An, H-S, Kang, S-K, Noble, JM, Berg, KE, and Lee, J-M. Concurrent validity of wearable activity trackers under free-living conditions. J Strength Cond Res 31(4): 1097-1106, 2017-The purpose of this study is to evaluate the concurrent validity of wearable activity trackers in energy expenditure (EE) and sleep period time (SPT) under free-living conditions. Ninety-five (28.5 ± 9.8 years) healthy men (n = 34) and women (n = 61) participated in this study. The total EE and SPT were measured using 8 monitors: Nike+ FuelBand SE (NFB), Garmin VivoFit (VF), Misfit Shine (MF), Fitbit Flex (FF), Jawbone UP (JU), Polar Loop (PL), Fitbit Charge HR (FC), and SenseWear Armband Mini (SWA) (criterion measures: SWA for EE and a sleep log for SPT). The mean absolute percent error (MAPE) for EE was 13.0, 15.2, 15.5, 16.1, 16.2, 22.8, and 24.5% for PL, MF, FF, NFB, FC, JU, and VF, respectively. Mean absolute percent errors were calculated for SPT to be 4.0, 8.8, 10.2, 11.5, 12.9, 13.6, 17.5, and 21.61% for VF, FF, JU, FC, MF, SWA laying down, PL, and SWA, respectively. Concurrent validity was examined using equivalence testing on EE (equivalence zone: 2,889.7-3,531.9 kcal); 2 trackers fell short of falling in the zone: PL (2,714.4-3,164.8 kcal) and FC (2,473.8-3,066.5 kcal). For SPT (equivalence zone: 420.6-514.0 minutes), several monitors fell in the zone: PL (448.3-485.6 minutes), MS (442.8-492.2 minutes), and FF (427.7-486.7 minutes). This study suggests that the PL and FC provide a reasonable estimate of EE under free-living conditions. The PL, FC, and MF were the most valid monitors used for measuring SPT.

AOSpine subaxial cervical spine injury classification system.

PURPOSE: This project describes a morphology-based subaxial cervical spine traumatic injury classification system. Using the same approach as the thoracolumbar system, the goal was to develop a comprehensive yet simple classification system with high intra- and interobserver reliability to be used for clinical and research purposes. METHODS: A subaxial cervical spine injury classification system was developed using a consensus process among clinical experts. All investigators were required to successfully grade 10 cases to demonstrate comprehension of the system before grading 30 additional cases on two occasions, 1 month apart. Kappa coefficients (κ) were calculated for intraobserver and interobserver reliability. RESULTS: The classification system is based on three injury morphology types similar to the TL system: compression injuries (A), tension band injuries (B), and translational injuries (C), with additional descriptions for facet injuries, as well as patient-specific modifiers and neurologic status. Intraobserver and interobserver reliability was substantial for all injury subtypes (κ = 0.75 and 0.64, respectively). CONCLUSIONS: The AOSpine subaxial cervical spine injury classification system demonstrated substantial reliability in this initial assessment, and could be a valuable tool for communication, patient care and for research purposes.

Comparison of V[Combining Dot Above]O2peak and Achievement of V[Combining Dot Above]O2peak Criteria in Three Modes of Exercise in Female Triathletes.

Snoza, CT, Berg, KE, and Slivka, DR. Comparison of V[Combining Dot Above]O2peak and achievement of V[Combining Dot Above]O2peak criteria in three modes of exercise in female triathletes. J Strength Cond Res 30(10): 2816-2822, 2016-The purpose of this study was to compare peak aerobic capacity in female triathletes in 3 modes of exercise: treadmill, cycle, and arm ergometer. A second purpose was to determine the extent that physiologic criteria for achieving V[Combining Dot Above]O2peak were reached in each mode of exercise. Six criteria were examined: V[Combining Dot Above]O2 plateau, heart rate (HR), blood lactate concentration (BLC), respiratory exchange ratio, oxygen saturation, and rating of perceived exertion (RPE). Twelve recreational level female triathletes completed maximal tests on the treadmill, stationary bike, and arm ergometer. Results indicated V[Combining Dot Above]O2peak (ml·kg·min) is highest on a treadmill (46.8 ± 2.1), intermediate in cycling (40.7 ± 5.0), and lowest in arm ergometry (28.2 ± 3.3) with mean differences being significant (p ≤ 0.05). Blood lactate concentration and RPE criteria were met by the highest number of subjects across the 3 modes of testing while the HR criterion was not achieved in any participant in arm ergometry and only 2 in cycling. It was concluded that in moderately trained recreational level triathletes, V[Combining Dot Above]O2peak is highest in running and lowest in arm ergometry. Criteria for achieving V[Combining Dot Above]O2peak most frequently were blood lactate level and RPE. Coaches and researchers should appreciate that V[Combining Dot Above]O2peak values of moderately trained triathletes differ considerably in contrast to elite triathletes and tend to be highest on the treadmill and lowest in arm ergometry. Also, criteria used to determine achievement of V[Combining Dot Above]O2peak should be carefully selected and seem to be best achieved using BLC and RPE.

YehZYXW of Escherichia coli Is a Low-Affinity, Non-Osmoregulatory Betaine-Specific ABC Transporter.

Transporter-mediated osmolyte accumulation stimulates the growth of Escherichia coli in high-osmolality environments. YehZYXW was predicted to be an osmoregulatory transporter because (1) osmotic and stationary phase induction of yehZYXW is mediated by RpoS, (2) the Yeh proteins are homologous to the components of known osmoregulatory ABC transporters (e.g., ProU of E. coli), and (3) YehZ models based on the structures of periplasmic betaine-binding proteins suggested that YehZ retains key betaine-binding residues. The betaines choline-O-sulfate, glycine betaine, and dimethylsulfoniopropionate bound YehZ and ProX with millimolar and micromolar affinities, respectively, as determined by equilibrium dialysis and isothermal titration calorimetry. The crystal structure of the YehZ apoprotein, determined at 1.5 Å resolution (PDB ID: 4WEP ), confirmed its similarity to other betaine-binding proteins. Small and nonpolar residues in the hinge region of YehZ (e.g., Gly223) pack more closely than the corresponding residues in ProX, stabilizing the apoprotein. Betaines bound YehZ-Gly223Ser an order of magnitude more tightly than YehZ, suggesting that weak substrate binding in YehZ is at least partially due to apo state stabilization. Neither ProX nor YehZ bound proline. Assays based on osmoprotection or proline auxotrophy failed to detect YehZYXW-mediated uptake of proline, betaines, or other osmolytes. However, transport assays revealed low-affinity glycine betaine uptake, mediated by YehZYXW, that was inhibited at high salinity. Thus, YehZYXW is a betaine transporter that shares substrate specificity, but not an osmoregulatory function, with homologues like E. coli ProU. Other work suggests that yehZYXW may be an antivirulence locus whose expression promotes persistent, asymptomatic bacterial infection.

Novel method for online monitoring of dissolved N2O concentrations through a gas stripping device.

Nitrous oxide emissions from wastewater treatment plants are currently measured by online gas phase analysis or grab sampling from the liquid phase. In this study, a novel method is presented to monitor the liquid phase N2O concentration for aerated as well as non-aerated conditions/reactors, following variations both in time and in space. The monitoring method consists of a gas stripping device, of which the measurement principle is based on a continuous flow of reactor liquid through a stripping flask and subsequent analysis of the N2O concentration in the stripped gas phase. The method was theoretically and experimentally evaluated for its fit for use in the wastewater treatment context. Besides, the influence of design and operating variables on the performance of the gas stripping device was addressed. This method can easily be integrated with online off-gas measurements and allows to better investigate the origin of the gas emissions from the treatment plant. Liquid phase measurements of N2O are of use in mitigation of these emissions. The method can also be applied to measure other dissolved gasses, such as methane, being another important greenhouse gas.

Postchemotherapy surgery for germ cell tumors--what have we learned in 35 years?

Postchemotherapy surgery for advanced testicular cancer has evolved over the last couple of decades. Patients with nonseminomatous germ cell tumors and residual retroperitoneal mass ≥1 cm should undergo postchemotherapy retroperitoneal lymph node dissection (RPLND). For seminoma, RPLND is considered in those patients with masses ≥3 cm that are also positron emission tomography positive. Masses that occur outside of the retroperitoneum should be completely resected with the possible exception of bilateral lung masses when resection of the first mass shows necrosis. The role of surgery in patients with extragonadal germ cell tumors is most vital in those with primary mediastinal nonseminomatous germ cell tumors. Importantly, patient selection, surgical planning, and consideration of referral to centers with this expertise are important to optimize success.

Cervical laminectomy width and spinal cord drift are risk factors for postoperative C5 palsy.

BACKGROUND: Cervical laminectomy and fusion (CLF) is a treatment option for multilevel cervical spondylotic myelopathy. Postoperative C5 nerve palsy is a possible complication of CLF. It has been suggested that C5 nerve palsy may be due to posterior drift of the spinal cord related to a wide laminectomy trough. PURPOSE: To test the hypothesis that excessive spinal cord drift into a wide laminectomy trough is associated with C5 palsy. STUDY DESIGN: Retrospective case-control study. PATIENT SAMPLE: Seventeen patients with C5 palsy, 8 patients as control group. OUTCOME MEASURES: Spinal cord positional measurements on magnetic resonance imaging (MRI). METHODS: All patients who underwent elective CLF for cervical spondylotic myelopathy or ossified posterior longitudinal ligament using posterior instrumentation between 2004 and 2008 were included. Patients who underwent CLF for trauma, infection, or tumors were excluded. Clinical and radiographic outcomes were assessed by chart review (minimum of 1 y follow-up). Patients who developed a new postoperative C5 nerve palsy underwent repeat MRI. The control group also underwent CLF, did not develop a neurological deficit, and received a postoperative MRI for evaluation of possible infection. MRI measurements included the width of the laminectomy trough, the distance from the posterior vertebral body or disk to the anterior spinal cord, the width of the spinal cord herniated into the laminectomy defect, and C2-7 sagittal alignment. Preoperative radiographic measurements included preoperative vertebral body diameter, spinal canal diameter, and sagittal vertical offset. RESULTS: There were seventeen patients with C5 nerve root palsy and 8 patients without C5 nerve root palsy. There were no baseline differences in fusion levels, instrumentation used, patient age, or sex. MRI measurements revealed an increase in mean postoperative cord drift in patients with C5 palsy at C3 (4.2 vs. 2.2 mm, P=0.002), C4 (4.6 vs. 2.8 mm, P=0.056), C5 (5.1 vs. 2.4 mm, P=0.011), and C6 (5.2 vs. 2.4 mm, P=0.003). There was a significant increase in C5 laminectomy trough width among patients with postoperative C5 palsy (17.9 vs. 15.2 mm, P=0.032), but there was no difference in sagittal alignment. CONCLUSIONS: A wider laminectomy at C5 was associated with an increased risk of postoperative C5 palsy. Increased preoperative spinal canal diameter is also associated with increased risk of C5 palsy. In addition, patients who experienced C5 nerve palsy had a significantly greater posterior spinal cord drift. Strategies to reduce postoperative laminectomy trough width and spinal cord drift may reduce the risk of postoperative C5 palsy.

Evaluation of Insecticides, Entomopathogenic Nematodes, and Physical Soil Barriers for Control of Diaprepes abbreviatus (Coleoptera: Curculionidae) in Citrus.

The Diaprepes root weevil, Diaprepes abbreviatus L. (Coleoptera: Curculionidae), was discovered as the cause of early decline and death of citrus trees and ornamental plants along coastal Orange and Los Angeles Counties in 2005 and San Diego County in 2006. We established trials to evaluate the effectiveness of two tactics to manage life stages of Diaprepes root weevil that are found in the soil. The first tactic was soil applications of the pesticides bifenthrin or imidacloprid, with and without entomopathogenic nematodes, to kill larvae. The second tactic was attempting to block adult emergence from the soil using a thick wood-chip mulch layer, a small-meshed landscape fabric, and a dry soil barrier (created by subirrigation). We found that soil treatments with the two insecticides (bifenthrin and imidacloprid) at maximum label rates with and without Steinernema riobrave Cabanillas et al. at 5 million nematodes per tree significantly reduced numbers of soil-borne Diaprepes root weevil larvae in one trial compared with the control. Another entomopathogenic nematode, Heterorhabditis indica Poinar et al. applied in wax moth Galleria mellonella L. cadavers at 86 wax moth cadavers per tree was not effective. Adult emergence was reduced by almost 100% when the landscape fabric was kept intact (2009), but emergence occurred in 2010 when the fabric was torn by grove operations (60% reduction). Adult emergence was reduced to ≍70% compared with the control in the subirrigation treatment in 2009 when the summer was hot and dry, but emergence occurred in 2010 during periodic rains toward the end of summer. The mulch treatment kept the soil moist in between irrigations resulting in greater adult emergence rates compared with controls during 2009 and 2010. Health ratings of the trees were taken following several years of physical barrier treatments, and trees treated with the landscape fabric were significantly healthier (mean rating 0.9, scale 0 = healthy to 5 = dead) than those in the other treatments (mean rating of 3.6, 4.0, and 2.5 for control, mulch and subirrigation, respectively). Of the physical barrier methods studied, landscape fabric is most effective in reducing Diaprepes root weevil emergence, increases plant health, and is long lasting, but it is the most costly to install and can be damaged during harvest.

Grunting in tennis increases ball velocity but not oxygen cost.

Grunting is widely used by professional tennis players, but no research has been done to verify enhanced performance with grunting. Therefore, the purpose of this study was to determine if grunting enhanced ball velocity in groundstrokes and secondly, to determine if grunting increased the physiological cost of hitting (VO2, HR, VE/VO2, and RPE). Participants were 10 members of the men's (n = 5) and women's (n = 5) tennis teams at a Division I university who had just completed their indoor competitive season. Two hitting sessions were used as players repetitively hit forehand and backhand shots while either grunting or not grunting. Each hitting session consisted of five 2-minute periods with a 1-minute break in between each period. Ball velocity was measured with a radar gun. During each hitting session, players wore a portable metabolic measuring unit. HR was monitored using a Polar monitor, and RPE was assessed using Borg's 6-20 scale. Grunting increased ball velocity (kph) 3.8% compared with non-grunting condition (p < 0.034) with the mean ± SD being 83.4 ± 0.6.1 and 80.3 ± 0.8.7, respectively. The physiological responses (VO2, HR, VE/VO2, and RPE) for the 2 hitting conditions were not significantly different for any variable. When averaged across both hitting conditions, HR over the 5-time periods was higher in periods 3-5 than period (p < 0.018) 1, whereas VE/VO2 and RPE were greater in periods 2-5 than period 1 (p = 0.001). RPE significantly increased over time with periods 2-5 being greater than period 1 (p = 0.001). It was concluded that grunting increased ball velocity without increasing VO2 or VE/VO2 or RPE in comparison with not grunting. It may be worthwhile for players and coaches in tennis and other sports to experiment with grunting to determine possible improvement in performance.

Microdiscectomy Insurance Medical Necessity Criteria Are Inconsistent and Unnecessarily Restrictive.

BACKGROUND: Microdiscectomy for patients with chronic lumbar radiculopathy refractory to conservative therapy has significantly better outcomes than continued nonoperative management. The North American Spine Society (NASS) outlined specific criteria to establish medical necessity for elective lumbar microdiscectomy. We hypothesized that insurance providers have substantial variability among one another and from the NASS guidelines. METHODS: A cross-sectional analysis of US national and local insurance companies was conducted to assess policies on coverage recommendations for lumbar microdiscectomy. Insurers were selected based on their enrollment data and market share of direct written premiums. The top 4 national insurance providers and the top 3 state-specific providers in New Jersey, New York, and Pennsylvania were selected. Insurance coverage guidelines were accessed through a web-based search, provider account, or telephone call to the specific provider. If no policy was provided, it was documented as such. Preapproval criteria were entered as categorical variables and consolidated into 4 main categories: symptom criteria, examination criteria, imaging criteria, and conservative treatment. RESULTS: The 13 selected insurers composed roughly 31% of the market share in the United States and approximately 82%, 62%, and 76% of the market share for New Jersey, New York, and Pennsylvania, respectively. Insurance descriptions of symptom criteria, imaging criteria, and the definition of conservative treatment had substantial differences as compared with those defined by NASS. CONCLUSION: Although a guideline to establish medical necessity was developed by NASS, many insurance companies have created their own guidelines, which have resulted in inconsistent management based on geographic location and selected provider. CLINICAL RELEVANCE: Providers must be cognizant of the differing preapproval criteria needed for each in-network insurance company in order to provide effective and efficient care for patients with lumbar radiculopathy.

A scalable MapReduce-based design of an unsupervised entity resolution system.

Traditional data curation processes typically depend on human intervention. As data volume and variety grow exponentially, organizations are striving to increase efficiency of their data processes by automating manual processes and making them as unsupervised as possible. An additional challenge is to make these unsupervised processes scalable to meet the demands of increased data volume. This paper describes the parallelization of an unsupervised entity resolution (ER) process. ER is a component of many different data curation processes because it clusters records from multiple data sources that refer to the same real-world entity, such as the same customer, patient, or product. The ability to scale ER processes is particularly important because the computation effort of ER increases quadratically with data volume. The Data Washing Machine (DWM) is an already proposed unsupervised ER system which clusters references from diverse data sources. This work aims at solving the single-threaded nature of the DWM by adopting the parallelization nature of Hadoop MapReduce. However, the proposed parallelization method can be applied to both supervised systems, where matching rules are created by experts, and unsupervised systems, where expert intervention is not required. The DWM uses an entropy measure to self-evaluate the quality of record clustering. The current single-threaded implementations of the DWM in Python and Java are not scalable beyond a few 1,000 records and rely on large, shared memory. The objective of this research is to solve the major two shortcomings of the current design of the DWM which are the creation and usage of shared memory and lack of scalability by leveraging on the power of Hadoop MapReduce. We propose Hadoop Data Washing Machine (HDWM), a MapReduce implementation of the legacy DWM. The scalability of the proposed system is displayed using publicly available ER datasets. Based on results from our experiment, we conclude that HDWM can cluster from 1,000's to millions of equivalent references using multiple computational nodes with independent RAM and CPU cores.

It's complicated: The relationship of non-narcotic medications and postoperative opioid use in radical cystectomy patients.

INTRODUCTION: The effect of individual non-narcotic analgesics in cystectomy enhanced recovery after surgery (ERAS) is unknown. Additionally, many non-narcotic medications are associated with side effects pertinent to the cystectomy population. To better understand the actual use and utility of these medications, we sought to characterize the association between non-narcotic medications and milligram morphine equivalent (MME) narcotic score during the postoperative inpatient stay. METHODS: We reviewed 260 consecutive ERAS cystectomy patients. The MME impact of non-narcotic compliance and cumulative dose of medication received was evaluated separately with general linear models. We also assessed relationship of non-narcotic compliance to patient reported pain score, length of stay (LOS), and time to return of bowel function (ROBF) and performed manual review of postoperative documentation to identify reasons for medication noncompliance. RESULTS: Compliance with postoperative acetaminophen, gabapentin, and ketorolac was low. There was an inverse relationship between ketorolac dose and MME on postoperative day 1 (-0.026 MME/mg; P = 0.004) and postoperative day 2 (-0.33 MME/mg; P < 0.001). Compliance with ketorolac was associated with lower MME on postoperative day 1 (26.1 MME v. 33.6 MME; P = 0.023). There were no such associations identified with gabapentin or acetaminophen. Gabapentin compliance was associated with earlier ROBF (3.7 days v. 4.3 days; P = 0.006). Ketorolac compliance was associated with lower pain score on POD1 (3.25 VAS v. 4.07 VAS; P = 0.019) and POD2 (3.05 VAS v. 3.85 VAS; P = 0.040) There was no association between medication compliance and LOS. The most common reasons identified for non-compliance with gabapentin and ketorolac were renal function concerns (38% and 40% respectively), bleeding concerns with ketorolac (20%) and concerns for neurologic adverse effect with gabapentin (16%). CONCLUSION: Compliance with non-narcotic medications in our ERAS cystectomy protocol was poor. There was a modest association with ketorolac and postoperative MME but no association with gabapentin or acetaminophen. Further study will clarify the role of these medications for cystectomy patients. Component specific analysis of protocolized care is valuable and may alter care pathways.

Impact of Socioeconomic Status on Patient Adherence in Managing Renal Masses.

INTRODUCTION: Previous literature suggests socioeconomic status and racial disparities impact management decisions for patients with small renal masses. We aim to build upon these findings and examine how these modalities impact patient adherence to their management plan. METHODS: This retrospective study analyzed our Kidney Tumor Program database (n = 1476) containing patients from 2000 to 2020. Socioeconomic status was estimated using 2 modalities: Area Deprivation Index and household income. Patients were then evaluated for differences in adherence, nonadherence, and loss to follow-up. Adherent patients completed all recommended appointments within 6 months of their initial follow-up. Nonadherent patients did not complete all recommended appointments within 6 months of their originally scheduled follow-up but eventually did. Patients lost to follow-up were recommended to follow up but never did. RESULTS: Patient adherence was not significantly different across sex or primary treatment method but differed with respect to race/ethnicity. Black patients were significantly more likely to be nonadherent (P = .021) and lost to follow-up (P = .008). After adjusting for race/ethnicity, Area Deprivation Index and income bracket were significantly associated with adherence and loss to follow-up. Patients with a high socioeconomic status had significantly higher rates of adherence (ADI, quartile [Q] 1 vs Q4, P = .038; income, >$120,000 vs $30,000-$59,999, P < .003) and decreased loss to follow-up (ADI, Q1 vs Q4, P = .03; income, >$120,000 vs $30,000-$59,999, P = .002). CONCLUSIONS: Our results demonstrate that Black race and low socioeconomic status are associated with decreased adherence and increased loss to follow-up. Possible strategies to target these disparities include financial assistance programming, social determinants of health screening, and nurse navigator programs.