An NBS-LRR protein in the Rpp1 locus negates the dominance of Rpp1-mediated resistance against Phakopsora pachyrhizi in soybean.

The soybean Rpp1 locus confers resistance to Phakopsora pachyrhizi, causal agent of rust, and resistance is usually dominant over susceptibility. However, dominance of Rpp1-mediated resistance is lost when a resistant genotype (Rpp1 or Rpp1b) is crossed with susceptible line TMG06_0011, and the mechanism of this dominant susceptibility (DS) is unknown. Sequencing the Rpp1 region reveals that the TMG06_0011 Rpp1 locus has a single nucleotide-binding site leucine-rich repeat (NBS-LRR) gene (DS-R), whereas resistant PI 594760B (Rpp1b) is similar to PI 200492 (Rpp1) and has three NBS-LRR resistance gene candidates. Evidence that DS-R is the cause of DS was reflected in virus-induced gene silencing of DS-R in Rpp1b/DS-R or Rpp1/DS-R heterozygous plants with resistance partially restored. In heterozygous Rpp1b/DS-R plants, expression of Rpp1b candidate genes was not significantly altered, indicating no effect of DS-R on transcription. Physical interaction of the DS-R protein with candidate Rpp1b resistance proteins was supported by yeast two-hybrid studies and in silico modeling. Thus, we conclude that suppression of resistance most likely does not occur at the transcript level, but instead probably at the protein level, possibly with Rpp1 function inhibited by binding to the DS-R protein. The DS-R gene was found in other soybean lines, with an estimated allele frequency of 6% in a diverse population, and also found in wild soybean (Glycine soja). The identification of a dominant susceptible NBS-LRR gene provides insight into the behavior of NBS-LRR proteins and serves as a reminder to breeders that the dominance of an R gene can be influenced by a susceptibility allele.

Genomic regions associated with resistance to soybean rust (Phakopsora pachyrhizi) under field conditions in soybean germplasm accessions from Japan, Indonesia and Vietnam.

KEY MESSAGE: Eight soybean genomic regions, including six never before reported, were found to be associated with resistance to soybean rust (Phakopsora pachyrhizi) in the southeastern USA. Soybean rust caused by Phakopsora pachyrhizi is one of the most important foliar diseases of soybean [Glycine max (L.) Merr.]. Although seven Rpp resistance gene loci have been reported, extensive pathotype variation in and among fungal populations increases the importance of identifying additional genes and loci associated with rust resistance. One hundred and ninety-one soybean plant introductions from Japan, Indonesia and Vietnam, and 65 plant introductions from other countries were screened for resistance to P. pachyrhizi under field conditions in the southeastern USA between 2008 and 2015. The results indicated that 84, 69, and 49% of the accessions from southern Japan, Vietnam or central Indonesia, respectively, had negative BLUP values, indicating less disease than the panel mean. A genome-wide association analysis using SoySNP50K Infinium BeadChip data identified eight genomic regions on seven chromosomes associated with SBR resistance, including previously unreported regions of Chromosomes 1, 4, 6, 9, 13, and 15, in addition to the locations of the Rpp3 and Rpp6 loci. The six unreported genomic regions might contain novel Rpp loci. The identification of additional sources of rust resistance and associated genomic regions will further efforts to develop soybean cultivars with broad and durable resistance to soybean rust in the southern USA.

Factors that impact a patient's experience when undergoing single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in the US: A survey of patients, imaging center staff, and physicians.

BACKGROUND: Single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) is commonly used for coronary artery disease diagnosis/assessment in the United States (US); however, the factors that most significantly affect patients' experience when undergoing SPECT-MPI are not well known. METHODS: In this US-based cross-sectional study, an online questionnaire was used to identify and quantify attributes of the SPECT-MPI process that impact patients' experience, according to adults who underwent SPECT-MPI in the prior month, cardiac imaging center staff, and referring physicians. Participants were asked to rate the importance of 32 factors using an 11-point scale; congruence between groups (physicians vs patients, patients vs imaging center staff, and physicians vs imaging center staff) was assessed. RESULTS: The survey was completed by 101 patients, 101 center staff, and 100 physicians, who gave similar ratings for the highest-rated factors (high-quality results/decreasing likelihood of having to retest, highly skilled and knowledgeable staff, and compassionate and respectful staff). Congruence was higher between patients and imaging center staff compared with physicians and patients, and was notably low between imaging center staff and physicians. CONCLUSIONS: We identified areas for improvement in the patient SPECT-MPI experience that could translate into improved quality and value.

Aphis glycines virus 1, a new bicistronic virus with two functional internal ribosome entry sites, is related to a group of unclassified viruses in the Picornavirales.

A novel picorna-like virus, provisionally named Aphis glycines virus 1 (ApGlV1) was discovered by high-throughput sequencing of soybean total RNAs and detected in suction trap-collected Aphis glycines. The ApGlV1 genome contains two large ORFs organized similar to those of dicipiviruses in the Picornaviridae where ORFs 1 and 2 encode structural and nonstructural proteins, respectively. Both ORFs are preceded by internal ribosome entry site (IRES) elements. The 5' IRES was more active in dual luciferase activity assays than the IRES in the intergenic region. The ApGlV1 genome was predicted to encode a serine protease instead of a cysteine protease and showed very low aa sequence identities to recognized members of the Picornavirales. In phylogenetic analyses based on capsid protein and RNA-dependent RNA polymerase sequences, ApGlV1 consistently clustered with a group of unclassified bicistronic picorna-like viruses discovered from arthropods and plants that may represent a novel family in the order Picornavirales.

Undertreatment of overactive bladder among men with lower urinary tract symptoms in the United States: A retrospective observational study.

AIMS: To characterize the epidemiology and treatment patterns of adult men (≥40 years) diagnosed with, or treated for, overactive bladder (OAB) and/or benign prostatic hyperplasia (BPH). METHODS: This retrospective observational study used data extracted from the IBM MarketScan Commercial Claims and Encounters database and the Medicare Supplemental Coordination of Benefits database. Men with BPH and/or OAB were identified and observed to assess treatment and diagnostic patterns. RESULTS: Within the entire study sample (N = 462 400), BPH diagnosis (61.5%) and BPH treatment (73.7%) were more common than the corresponding values for OAB (25.8% and 7.0%, respectively). Notably, among diagnosed individuals, the dispensation of a corresponding treatment was more likely in individuals diagnosed with BPH (183 672 out of 284 416 = 64.6%) compared with OAB (16 468 out of 119 236 = 13.8%). Among newly diagnosed and/or treated patients (n = 196 576), only 60.3% received treatment. Among treated patients, most experienced only a single type of treatment (93.4%), 6.6% went on to receive a secondary treatment and 3.5% a tertiary. The most common primary treatment was alpha-blocker monotherapy (76.9%) followed by tadalafil monotherapy (16.4%). Among those untreated at first diagnosis, the median time between diagnosis and treatment initiation was 128 days. CONCLUSIONS: Diagnosis and management of OAB among males are challenging given the inherent overlap in symptoms observed with BPH. Unsurprisingly, we found that BPH is diagnosed and treated more frequently than OAB; but the differences between diagnosis and treatment patterns for the two conditions highlight the potential undertreatment of OAB and misdirection of therapy for men with a combination of voiding and storage symptoms.

Reactions of Soybean Germplasm Accessions to Six Phakopsora pachyrhizi Isolates from the United States.

Soybean rust, caused by Phakopsora pachyrhizi Syd. & P. Syd., is one of the most economically important foliar diseases of soybean. Resistant cultivars could reduce yield losses and management costs but considerable pathogenic diversity exists among populations of the fungus; thus, resistance to a range of pathotypes is essential. Seedling and detached-leaf assays were conducted to characterize the resistance of 55 soybean plant introductions (PIs) to six purified isolates of P. pachyrhizi originating from the southern United States. In the greenhouse resistance assays, the differentials Hyuuga (PI 506764) and PI 471904 and accessions PI 224268, PI 567025A, PI 567039, PI 567046A, and DT 2000 (PI 635999) were resistant to all six isolates, including Florida isolates from 2011 and 2012 that were able to defeat resistance conditioned by the Rpp1 through Rpp4 genes. Twenty-six other PIs were resistant to four or five of the six isolates. In the detached-leaf assays, eight accessions developed reddish-brown reactions to all six isolates, with an average of only 0.23 to 0.55 uredinia/lesion. These included Hyuuga, DT 2000, two differentials with a resistance allele at the Rpp5 locus, and accessions PI 224268, PI 423960B, PI 567025A, and PI 567046A. Many of the resistant accessions have subsequently been reported to have a resistance allele at the Rpp3 locus, and two others have resistance genes at the Rpp4 or Rpp6 locus. This study provided new information about resistance reaction phenotypes that can be useful for understanding mechanisms of resistance, which Rpp genes and alleles could be combined to obtain broader and more durable rust resistance in soybean cultivars, and pathotype diversity among the six isolates used.

Discovery of a seventh Rpp soybean rust resistance locus in soybean accession PI 605823.

KEY MESSAGE: A novel Rpp gene from PI 605823 for resistance to Phakopsora pachyrhizi was mapped on chromosome 19. Soybean rust, caused by the obligate biotrophic fungal pathogen Phakopsora pachyrhizi Syd. & P. Syd, is a disease threat to soybean production in regions of the world with mild winters. Host plant resistance conditioned by resistance to P. pachyrhizi (Rpp) genes has been found in numerous soybean accessions, and at least 10 Rpp genes or alleles have been mapped to six genetic loci. Identifying additional disease-resistance genes will facilitate development of soybean cultivars with durable resistance. PI 605823, a plant introduction from Vietnam, was previously identified as resistant to US populations of P. pachyrhizi in greenhouse and field trials. In this study, bulked segregant analysis using an F2 population derived from 'Williams 82' × PI 605823 identified a genomic region associated with resistance to P. pachyrhizi isolate GA12, which had been collected in the US State of Georgia in 2012. To further map the resistance locus, linkage mapping was carried out using single-nucleotide polymorphism markers and phenotypic data from greenhouse assays with an F2:3 population derived from Williams 82 × PI 605823 and an F4:5 population derived from '5601T' × PI 605823. A novel resistance gene, Rpp7, was mapped to a 154-kb interval (Gm19: 39,462,291-39,616,643 Glyma.Wm82.a2) on chromosome 19 that is different from the genomic locations of any previously reported Rpp genes. This new gene could be incorporated into elite breeding lines to help provide more durable resistance to soybean rust.

Method for Tuneable Homeotropic Anchoring at Microstructures in Liquid Crystal Devices.

A simple method for vapour-phase deposition of a silane surfactant is presented, which produces tuneable homeotropic anchoring in liquid crystals. Both the zenithal anchoring energy and surface slip are measured by fitting to the latching threshold versus pulse width characteristic of a zenithal bistable nematic liquid crystal device based on a deep, submicron grating. The method is shown to give microscopic anchoring strength between 5 × 10-5 and 2 × 10-4 J/m2, with a surface slip of about 100 nm. The silanated surfaces are characterized using atomic force microscopy and X-ray photoelectron spectroscopy, which show a direct relationship between the surface coverage of silane groups and the resulting anchoring energy.

Identification of a soybean rust resistance gene in PI 567104B.

KEY MESSAGE: Using a combination of phenotypic screening and molecular, statistical, and linkage analyses, we have mapped a dominant soybean rust resistance gene in soybean PI 567104B. Asian soybean rust (SBR), caused by the fungus Phakopsora pachyrhizi Syd. and P. Syd., is one of the most economically important diseases that affect soybean production worldwide. A long-term strategy for minimizing the effects of SBR is the development of genetically resistant cultivars. The objectives of the study were to identify the location of a rust-resistance (Rpp) gene(s) in plant introduction (PI) 567104B, and to determine if the gene(s) in PI 567104B was different from previously mapped Rpp loci. The progeny of the cross of 'IAR 2001 BSR' × PI 567104B was phenotyped from field assays of the F 2:3 and F 4:5 generations and from a growth chamber assay of 253 F 5:6 recombinant inbred lines (RILs). For the growth chamber, the phenotyping was conducted by inoculation with a purified 2006 fungal isolate from Mississippi. A resistance gene locus on PI 567104B was mapped to a region containing the Rpp6 locus on chromosome 18. The high level of resistance of F 1 plants from two other crosses with PI 567104B as one of the parents indicated that the gene from PI 567104B was dominant. The interval containing the gene is flanked by the simple sequence repeat (SSR) markers Satt131 and Satt394, and includes the SSR markers BARCSOYSSR_18_0331 and BARCSOYSSR_18_0380. The results also indicated that the resistance gene from PI 567104B is different from the Rpp1 to the Rpp4 genes previously identified. To determine if the gene from PI 567104B is different from the Rpp6 gene from PI 567102B, additional research will be required.

How sensitive is the deltoid moment arm to humeral offset changes with reverse total shoulder arthroplasty?

BACKGROUND: Reverse total shoulder arthroplasty commonly treats cuff-deficient or osteoarthritic shoulders not amenable to rotator cuff repair. This study investigates deltoid moment arm sensitivity to variations in the joint center and humeral offset of 3 representative reverse total shoulder arthroplasty subjects. We hypothesized that a superior joint implant placement may exist, indicated by muscle moment arms, compared with the current actual surgical implant configuration. METHODS: Moment arms for the anterior, lateral, and posterior aspects of the deltoid muscle were determined for 1521 perturbations of the humeral offset location away from the surgical placement in a subject-specific musculoskeletal model with motion defined by subject-specific in vivo abduction kinematics. The humeral offset was varied from its surgical position ±4 mm in the anterior/posterior direction, ±12 mm in the medial/lateral direction, and -10 to 14 mm in the superior/inferior direction. RESULTS: The anterior deltoid moment arm varied in humeral offset and center of rotation up to 20 mm, primarily in the medial/lateral and superior/inferior directions. The lateral deltoid moment arm varied in humeral offset up to 20 mm, primarily in the medial/lateral and anterior/posterior directions. The posterior deltoid moment arm varied up to 15 mm, primarily in early abduction, and was most sensitive to humeral offset changes in the superior/inferior direction. DISCUSSION: High variations in muscle moment arms were found for all 3 deltoid components, presenting an opportunity to dramatically change the deltoid moment arms through surgical placement of the reverse shoulder components and by varying the overall offset of the humerus. LEVEL OF EVIDENCE: Basic Science Study; Computer Modeling.

How do deltoid muscle moment arms change after reverse total shoulder arthroplasty?

BACKGROUND: Although many advantages of reverse total shoulder arthroplasty (RTSA) have been demonstrated, a variety of complications indicate there is much to learn about how RTSA modifies normal shoulder function. This study used a subject-specific computational model driven by in vivo kinematic data to assess how RTSA affects deltoid muscle moment arms after surgery. METHODS: A subject-specific 12 degree-of-freedom musculoskeletal model was used to analyze the shoulders of 26 individuals (14 RTSA and 12 normal). The model was modified from the work of Holzbaur to directly input 6 degree-of-freedom humeral and scapular kinematics obtained using fluoroscopy. RESULTS: The moment arms of the anterior, lateral, and posterior aspects of the deltoid were significantly different when RTSA and normal cohorts were compared at different abduction angles. Anterior and lateral deltoid moment arms were significantly larger in the RTSA group at the initial elevation of the arm. The posterior deltoid was significantly larger at maximum elevation. There was large intersubject variability within the RTSA group. CONCLUSIONS: Placement of implant components during RTSA can directly affect the geometric relationship between the humerus and scapula and the muscle moment arms in the RTSA shoulder. RTSA shoulders maintain the same anterior and posterior deltoid muscle moment-arm patterns as healthy shoulders but show much greater intersubject variation and larger moment-arm magnitudes. These observations provide a basis for determining optimal implant configuration and surgical placement to maximize RTSA function in a patient-specific manner.

From Select Agent to an Established Pathogen: The Response to Phakopsora pachyrhizi (Soybean Rust) in North America.

The pathogen causing soybean rust, Phakopsora pachyrhizi, was first described in Japan in 1902. The disease was important in the Eastern Hemisphere for many decades before the fungus was reported in Hawaii in 1994, which was followed by reports from countries in Africa and South America. In 2004, P. pachyrhizi was confirmed in Louisiana, making it the first report in the continental United States. Based on yield losses from countries in Asia, Africa, and South America, it was clear that this pathogen could have a major economic impact on the yield of 30 million ha of soybean in the United States. The response by agencies within the United States Department of Agriculture, industry, soybean check-off boards, and universities was immediate and complex. The impacts of some of these activities are detailed in this review. The net result has been that the once dreaded disease, which caused substantial losses in other parts of the world, is now better understood and effectively managed in the United States. The disease continues to be monitored yearly for changes in spatial and temporal distribution so that soybean growers can continue to benefit by knowing where soybean rust is occurring during the growing season.

Liver-specific case fatality due to chronic hepatitis C virus infection: a systematic review.

Despite reports that mortality is increasing, overall case fatality due to hepatitis C virus (HCV) is thought to be low. Given the variability in published rates, we aimed to synthesize estimates of liver-specific case fatality and all-cause mortality in chronic HCV according to follow-up duration, sustained viral response (SVR) to treatment, and liver disease severity. A systematic review was conducted of studies published in English from 2003 to 2013, reporting liver-specific case fatality estimates from HCV-infected samples. Thirty-five eligible articles were identified; 26 also presented estimates of all-cause mortality. Among community-based samples, liver-specific case fatality ranged from 0.3% over 5.7 years to 9.2% over 8.2 years of follow-up; and of all-cause mortality, from 4.0% over 5.7 years, to 23.0% over 8.2 years of follow-up. Estimates were higher among clinic-based samples and those with more severe liver disease. Among treated patients achieving SVR, liver-specific case fatality was low: up to 1.4% over 11.5 years of follow-up among samples with any severity of liver disease. Estimates were higher among those without SVR: up to 14.0% over 10 years of followup among samples with any severity of liver disease, and higher still among samples with more severe liver disease. The proportion of deaths attributable to liver-specific causes ranged from 55 to 85% among those with severe liver disease. Published estimates of fatality are high among certain populations of chronic HCV patients, with liver-specific causes being an important contributor. Understanding current HCV mortality rates is important for quantifying the total burden of HCV disease.

Pathogenic diversity of Phytophthora sojae and breeding strategies to develop Phytophthora-resistant soybeans.

Phytophthora stem and root rot, caused by Phytophthora sojae, is one of the most destructive diseases of soybean [Glycine max (L.) Merr.], and the incidence of this disease has been increasing in several soybean-producing areas around the world. This presents serious limitations for soybean production, with yield losses from 4 to 100%. The most effective method to reduce damage would be to grow Phytophthora-resistant soybean cultivars, and two types of host resistance have been described. Race-specific resistance conditioned by single dominant Rps ("resistance to Phytophthora sojae") genes and quantitatively inherited partial resistance conferred by multiple genes could both provide protection from the pathogen. Molecular markers linked to Rps genes or quantitative trait loci (QTLs) underlying partial resistance have been identified on several molecular linkage groups corresponding to chromosomes. These markers can be used to screen for Phytophthora-resistant plants rapidly and efficiently, and to combine multiple resistance genes in the same background. This paper reviews what is currently known about pathogenic races of P. sojae in the USA and Japan, selection of sources of Rps genes or minor genes providing partial resistance, and the current state and future scope of breeding Phytophthora-resistant soybean cultivars.

Evaluating and understanding combination therapy decision drivers for the treatment of overactive bladder in the United States.

OBJECTIVE: To understand factors guiding overactive bladder (OAB) therapy selection and experience with combination therapy (antimuscarinics and beta-3 agonists). METHODS: Cross-sectional surveys of OAB patients and OAB-treating physicians in the USA were conducted. Patients receiving monotherapy with antimuscarinics were categorized by OAB treatment history: monotherapy only; third-line procedures (e.g., onabotulinumtoxinA injections) and combination therapy; third-line therapy only; and combination therapy only. The patient survey assessed therapy choice drivers and barriers, treatment satisfaction and sociodemographic/clinical characteristics. The physician survey assessed drivers of and barriers to OAB treatment choices. RESULTS: Of 200 patients, 86.5% reported involvement in treatment decision-making; doctor's recommendation was the most frequently considered factor (84.4%). Most patients (71%) were unaware of combination therapy. The primary reason why those patients aware of combination therapy had not used it (N = 43/200; 21%) was physician recommendation of other treatments (69.8%). For physicians (N = 50), the most frequently considered factors when prescribing OAB treatment were effectiveness (92.0%) and side effects (84.0%); 70% prescribed combination therapy, primarily for symptom severity (82.9%). The main reasons for not prescribing combination therapy were cost/insurance coverage (80%) and lack of information (53.3%). CONCLUSIONS: Shared decision-making guided treatment decisions; the main considerations were treatment safety and efficacy.

Health-related quality of life of patients recieving hemodialysis and peritoneal dialysis in São Paulo, Brazil: a longitudinal study.

OBJECTIVES: The aim of this study was to evaluate quality of life in patients undergoing hemodialysis (HD) or peritoneal dialysis (PD) in São Paulo, Brazil. METHODS: Inclusion criteria for this is a 1-year prospective study included being 18 years of age or older and clinically stable receiving chronic dialysis. Quality of life was measured using the SF-12 and the Kidney Disease Quality of Life questionnaires at baseline, 6 months, and 12 months. Patients who completed the surveys for all three periods were evaluated. Differences in quality of life scores were measured using univariate and multivariate regression analyses. RESULTS: One hundred eighty-nine of 249 (76%) HD patients and 161 of 228 (71%) PD patients completed all three surveys. The PD group was older and a larger number had diabetes. PD patients consistently had higher scores than HD patients at all three measurement periods for patient satisfaction (P = 0.002, P = 0.005, and P = 0.005, respectively), encouragement/support from staff (P = 0.003, P = 0.017, and P = 0.029, respectively), and burden of kidney disease (P = 0.003, P = 0.017, and P = 0.057, respectively). The HD group had a greater percent of patients who clinically improved from baseline to 12 months compared to PD patients for sleep quality, social support, encouragement/support from staff, and overall health. Scores for other dimensions of the Kidney Disease Quality of Life and SF-12 questionnaires were not significantly different between the PD and HD groups. CONCLUSIONS: The results provide evidence that PD and HD patients have equivalent health-related quality of life in several domains, although the former performed better in some quality of life domains despite being older and having more comorbidities.

Fall/Fracture-Related Healthcare Costs and Their Association with Cumulative Anticholinergic Burden in People with Overactive Bladder.

BACKGROUND: Falls/fractures are major causes of morbidity and mortality among older adults and the resulting health consequences generate a substantial economic burden. Risk factors are numerous and include overactive bladder (OAB) and anticholinergic use. OBJECTIVES: We aimed to estimate the impact of falls/fractures on all-cause healthcare resource utilization and costs, according to levels of cumulative anticholinergic burden, among individuals with OAB. METHODS: Among a US cohort of adults with OAB (identified based on medical claims for OAB or OAB-specific medications), the frequency of resource utilization (outpatients visits, medication use, and hospitalizations) was examined according to level of anticholinergic burden. Anticholinergic burden was assessed cumulatively using a published measure, and categorized as no, low, medium, or high. Resource utilization prior to and after a fall/fracture was compared. Generalized linear models were used to examine overall and incremental changes in healthcare resource utilization and costs by fall/fracture status, and annual costs were predicted according to age, sex, fall/fracture status, and level of anticholinergic burden. RESULTS: The mean age of the OAB cohort (n = 154,432) was 56 years, 68% were female, and baseline mean anticholinergic burden was 266.7 (i.e. a medium level of burden); a fall/fracture was experienced by 9.9% of the cohort. All estimates of resource utilization were higher among those with higher levels of anticholinergic burden, regardless of fall/fracture status, and higher for all levels of anticholinergic burden after a fall/fracture. Among those with a fall/fracture, the highest predicted annual costs were observed among those aged 66-75 years with high anticholinergic burden (US$22,408 for males, US$22,752 for females). CONCLUSIONS: Falls/fractures were associated with higher costs, which increased with increasing anticholinergic burden.

Comparative Safety and Efficacy of Treatments for Overactive Bladder Among Older Adults: A Network Meta-analysis.

BACKGROUND: Cumulative exposure to one or more anticholinergic medications ("anticholinergic burden") is associated with an increased risk of adverse outcomes, particularly among older individuals. Mirabegron, an oral selective ß3-adrenergic receptor agonist, has demonstrated efficacy in managing the symptoms of overactive bladder without contributing to anticholinergic burden. However, it is not known whether the favorable safety profile of mirabegron relative to antimuscarinics varies with increasing age among a patient population who may have a high anticholinergic burden. OBJECTIVE: The primary objective of this study was to indirectly compare the safety and efficacy profile of mirabegron relative to antimuscarinics in older adults with overactive bladder. METHODS: A systematic literature review was conducted to identify randomized controlled trials that reported safety and efficacy endpoints among patients aged ≥ 65 years. Identified randomized controlled trials were subsequently synthesized via a network meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in designing, performing, and reporting the literature review were followed. In line with current best practices, the network meta-analysis was conducted using a Bayesian approach and according to the overall general guidance for evidence synthesis developed by the National Institute for Health and Care Excellence decision support unit. Estimates of relative safety were assessed via the odds ratio and estimates of relative efficacy were assessed via means and credible intervals. RESULTS: A total of 3078 abstracts, 300 of which underwent full-text screening, were identified using the search criteria. Twenty articles reporting on 21 randomized controlled trials were eligible for data extraction and synthesis. Following review, five safety and five efficacy endpoints were considered for inclusion in the network meta-analysis. Regarding findings typical of anticholinergic exposure in older adults, mirabegron was not associated with an increased odds of dry mouth (odds ratio 95% credible interval 0.76 [0.26-2.37]) or constipation (1.08 [0.39-3.02]) relative to placebo, whereas antimuscarinics were strongly associated with these events (odds ratio range 3.78-7.85 and 2.12-4.66, respectively). In this older population, mirabegron was associated with a similar odds of experiencing adverse event-related treatment discontinuations relative to placebo (0.99 [0.57-1.70]), while the odds of experiencing an adverse event-related treatment discontinuation for antimuscarinics had a range of 1.14-3.03 (in most cases, the association was mild). No increased odds of experiencing overall treatment-emergent adverse events was observed for mirabegron or antimuscarinics (odds ratio range 1.25-1.55), apart from fesoterodine (2.23 [1.37-3.37]). Finally, a similar treatment effect was observed across all efficacy endpoints between mirabegron and antimuscarinics in this older population. CONCLUSIONS: This study indicates that the safety and efficacy profile of mirabegron remains favorable compared with antimuscarinics among older adults. This includes safety outcomes typically associated with anticholinergic burden, which were less frequently observed in patients treated with mirabegron.

The financial implications for Medicare of greater use of peritoneal dialysis.

BACKGROUND: Although annual per-person health care costs for patients with end-stage renal disease (ESRD) on in-center hemodialysis greatly exceed those for patients on peritoneal dialysis (PD), which is a home dialysis therapy, current use of PD remains low. In April 2008, the Centers for Medicare & Medicaid Services issued a new Dialysis Conditions of Coverage final rule underscoring its intent to promote use of home dialysis whenever appropriate. OBJECTIVES: The objectives of this paper were to provide context for the use of in-home versus in-center dialysis, to describe factors that influence patterns of dialysis utilization in the United States, and to explore the magnitude of the potential savings that might result from broader use of home dialysis therapies. METHODS: A 5-year budget-impact analysis was performed using data from the 2007 Annual Data Report of the United States Renal Data System. Scenarios were developed in which the PD share of total dialysis was varied to estimate the impact on total Medicare dialysis costs. This study took the perspective of Medicare, the main payer for dialysis in the United States. RESULTS: If the PD share of total dialysis were to decrease from the current 8% to 5%, Medicare spending for dialysis would increase by an additional $401 million over a 5-year period. Alternatively, if the PD share of total dialysis were to increase to 15%, Medicare could realize potential savings of >$1.1 billion over 5 years. CONCLUSIONS: Similar to the conclusion articulated in the Dialysis Conditions of Coverage final rule, increasing clinically appropriate use of PD would be associated with considerable savings to Medicare and to the taxpayers who fund Medicare. These savings could be used to offset part of the financial burden of ESRD care on Medicare and to help legislators meet ever-tightening budgetary constraints.

Gaining efficiencies: resources and demand for dialysis around the globe.

OBJECTIVES: End-stage renal disease (ESRD) is a debilitating condition resulting in death unless treated. Treatment options are transplantation and dialysis. Alternative dialysis modalities are peritoneal dialysis (PD) and hemodialysis (HD), each of which has been shown to produce similar outcomes and survival. Nevertheless, the financial implications of each modality are different and these differences vary by country, especially in the developing world. Changes in clinically appropriate dialysis delivery leading to more efficient use of resources would increase the resources available to treat ESRD or other disabling conditions. This article outlines the relative advantages of HD and PD and uses budget impact analysis to estimate the country-specific, 5-year financial implications on total dialysis costs assuming utilization shifts from HD to PD in two high-income (UK, Singapore), three upper-middle-income (Mexico, Chile, Romania), and three lower-middle-income (Thailand, China, Colombia) countries. RESULTS: Peritoneal dialysis is a clinically effective dialysis option that can be significantly cost-saving compared to HD, even in developing countries. CONCLUSIONS: The magnitude of costs associated with treating ESRD patients globally is large and growing. PD is a clinically effective dialysis option that can be used by a majority of ESRD patients and can also be significantly cost-saving compared to HD therapy. Increasing clinically appropriate PD use would substantially reduce health-care costs and help health-care systems meet ever-tightening budget constraints.