Obesity and "obesity-related" cancers: are there body mass index cut-points?

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.

Seaweed-Based Compounds and Products for Sustainable Protection against Plant Pathogens.

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.

Synaptogyrin-2 influences replication of Porcine circovirus 2.

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.

Effects of phosphite as a plant biostimulant on metabolism and stress response for better plant performance in Solanum tuberosum.

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.

A Novel Protein from Ectocarpus sp. Improves Salinity and High Temperature Stress Tolerance in Arabidopsis thaliana.

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.

Exogenous phosphite application alleviates the adverse effects of heat stress and improves thermotolerance of potato (Solanum tuberosum L.) seedlings.

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.

Association Between Hospital Participation in Medicare Shared Savings Program Accountable Care Organizations and Readmission Following Major Surgery.

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.

Characterising 'bounce-back' readmissions after radical cystectomy.

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.

Characterising potential bone scan overuse amongst men treated with radical prostatectomy.

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.

Role of Post-Acute Care on Hospital Readmission After High-Risk Surgery.

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.

Medicare Accountable Care Organizations and Use of Potentially Low-Value Procedures.

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.

Variation in prostate cancer treatment and spending among Medicare shared savings program accountable care organizations.

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.

Early effect of Medicare Shared Savings Program accountable care organization participation on prostate cancer care.

BACKGROUND: Accountable care organizations (ACOs) can improve prostate cancer care by decreasing treatment variations (ie, avoidance of treatment in low-value settings). Herein, the authors performed a study to understand the effect of Medicare Shared Savings Program ACOs on prostate cancer care. METHODS: Using a 20% Medicare sample, the authors identified men with newly diagnosed prostate cancer from 2010 through 2013. Rates of treatment, potential overtreatment (ie, treatment in men with a ≥75% chance of 10-year mortality from competing risks), and Medicare payments were measured using regression models. The impact of ACO participation was assessed using difference-in-differences analyses. RESULTS: Before implementation of ACOs, the treatment rate was 71.8% (95% confidence interval [95% CI], 70.2%-73.3%) for ACO-aligned beneficiaries and 72.3% (95% CI, 71.7%-73.0% [P = .51]) for non-ACO-aligned beneficiaries. After implementation, this rate declined to 68.4% (95% CI, 66.1%-70.7% [P = .017]) for ACO-aligned beneficiaries and 69.3% (95% CI, 68.5%-70.1% [P<.001]) for non-ACO-aligned beneficiaries. There was no differential effect noted for ACO participation. The rate of potential overtreatment decreased from 48.2% (95% CI, 43.1%-53.3%) to 40.2% (95% CI, 32.4%-48.0% [P = .087]) for ACO-aligned beneficiaries and increased from 44.3% (95% CI, 42.1%-46.5%) to 47.0% (95% CI, 44.5%-49.5% [P = .11]) for non-ACO-aligned beneficiaries. These changes resulted in a significant relative decrease in overtreatment of 17% for ACO-aligned beneficiaries (difference-in-differences, 10.8%; P = .031). Payments were not found to be differentially affected by ACO alignment. CONCLUSIONS: The treatment of prostate cancer and annual payments decreased significantly between 2010 and 2013, but ACO participation did not appear to impact these trends. Among men least likely to benefit, Medicare Shared Savings Program ACO alignment was associated with a significant decline in prostate cancer treatment. Cancer 2018;124:563-70. © 2017 American Cancer Society.

The implications of baseline bone-health assessment at initiation of androgen-deprivation therapy for prostate cancer.

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.

Predictors and Cost of Readmission in Total Knee Arthroplasty.

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.

Variation in readmission expenditures after high-risk surgery.

BACKGROUND: The Hospital Readmissions Reduction Program reduces payments to hospitals with excess readmissions for three common medical conditions and recently extended its readmission program to surgical patients. We sought to investigate readmission intensity as measured by readmission cost for high-risk surgeries and examine predictors of higher readmission costs. MATERIALS AND METHODS: We used the Healthcare Cost and Utilization Project's State Inpatient Database to perform a retrospective cohort study of patients undergoing major chest (aortic valve replacement, coronary artery bypass grafting, lung resection) and major abdominal (abdominal aortic aneurysm repair [open approach], cystectomy, esophagectomy, pancreatectomy) surgery in 2009 and 2010. We fit a multivariable logistic regression model with generalized estimation equations to examine patient and index admission factors associated with readmission costs. RESULTS: The 30-d readmission rate was 16% for major chest and 22% for major abdominal surgery (P < 0.001). Discharge to a skilled nursing facility was associated with higher readmission costs for both chest (odds ratio [OR]: 1.99; 95% confidence interval [CI]: 1.60-2.48) and abdominal surgeries (OR: 1.86; 95% CI: 1.24-2.78). Comorbidities, length of stay, and receipt of blood or imaging was associated with higher readmission costs for chest surgery patients. Readmission >3 wk after discharge was associated with lower costs among abdominal surgery patients. CONCLUSIONS: Readmissions after high-risk surgery are common, affecting about one in six patients. Predictors of higher readmission costs differ among major chest and abdominal surgeries. Better identifying patients susceptible to higher readmission costs may inform future interventions to either reduce the intensity of these readmissions or eliminate them altogether.

More Than Words: Defining Adjuvant, Consolidative, and Salvage Treatment after Radical Prostatectomy.

After radical prostatectomy, adjuvant therapy should be used sparingly when prostate-specific antigen (PSA) is undetectable. Instead, early salvage therapy is recommended for PSA recurrence. Patients with PSA persistence after prostatectomy are at high risk and should be offered consolidative therapy.

Incidental Prostate Cancer Diagnosis Is Common After Holmium Laser Enucleation of the Prostate.

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.