Wastewater surveillance beyond COVID-19: a ranking system for communicable disease testing in the tri-county Detroit area, Michigan, USA.

Introduction: Throughout the coronavirus disease 2019 (COVID-19) pandemic, wastewater surveillance has been utilized to monitor the disease in the United States through routine national, statewide, and regional monitoring projects. A significant canon of evidence was produced showing that wastewater surveillance is a credible and effective tool for disease monitoring. Hence, the application of wastewater surveillance can extend beyond monitoring SARS-CoV-2 to encompass a diverse range of emerging diseases. This article proposed a ranking system for prioritizing reportable communicable diseases (CDs) in the Tri-County Detroit Area (TCDA), Michigan, for future wastewater surveillance applications at the Great Lakes Water Authority's Water Reclamation Plant (GLWA's WRP). Methods: The comprehensive CD wastewater surveillance ranking system (CDWSRank) was developed based on 6 binary and 6 quantitative parameters. The final ranking scores of CDs were computed by summing the multiplication products of weighting factors for each parameter, and then were sorted based on decreasing priority. Disease incidence data from 2014 to 2021 were collected for the TCDA. Disease incidence trends in the TCDA were endowed with higher weights, prioritizing the TCDA over the state of Michigan. Results: Disparities in incidences of CDs were identified between the TCDA and state of Michigan, indicating epidemiological differences. Among 96 ranked CDs, some top ranked CDs did not present relatively high incidences but were prioritized, suggesting that such CDs require significant attention by wastewater surveillance practitioners, despite their relatively low incidences in the geographic area of interest. Appropriate wastewater sample concentration methods are summarized for the application of wastewater surveillance as per viral, bacterial, parasitic, and fungal pathogens. Discussion: The CDWSRank system is one of the first of its kind to provide an empirical approach to prioritize CDs for wastewater surveillance, specifically in geographies served by centralized wastewater collection in the area of interest. The CDWSRank system provides a methodological tool and critical information that can help public health officials and policymakers allocate resources. It can be used to prioritize disease surveillance efforts and ensure that public health interventions are targeted at the most potentially urgent threats. The CDWSRank system can be easily adopted to geographical locations beyond the TCDA.

Practical synthesis of the therapeutic leads tigilanol tiglate and its analogues.

Tigilanol tiglate is a natural product diterpenoid in clinical trials for the treatment of a broad range of cancers. Its unprecedented protein kinase C isoform selectivity make it and its analogues exceptional leads for PKC-related clinical indications, which include human immunodeficiency virus and AIDS eradication, antigen-enhanced cancer immunotherapy, Alzheimer's disease and multiple sclerosis. Currently, the only source of tigilanol tiglate is a rain forest tree, Fontainea picrosperma, whose limited number and restricted distribution (northeastern Australia) has prompted consideration of designed tree plantations to address supply needs. Here we report a practical laboratory synthesis of tigilanol tiglate that proceeds in 12 steps (12% overall yield, >80% average yield per step) and can be used to sustainably supply tigilanol tiglate and its analogues, the latter otherwise inaccessible from the natural source. The success of this synthesis is based on a unique strategy for the installation of an oxidation pattern common to many biologically active tiglianes, daphnanes and their analogues.

Five-week warning of COVID-19 peaks prior to the Omicron surge in Detroit, Michigan using wastewater surveillance.

Wastewater-based epidemiology (WBE) is useful in predicting temporal fluctuations of COVID-19 incidence in communities and providing early warnings of pending outbreaks. To investigate the relationship between SARS-CoV-2 concentrations in wastewater and COVID-19 incidence in communities, a 12-month study between September 1, 2020, and August 31, 2021, prior to the Omicron surge, was conducted. 407 untreated wastewater samples were collected from the Great Lakes Water Authority (GLWA) in southeastern Michigan. N1 and N2 genes of SARS-CoV-2 were quantified using RT-ddPCR. Daily confirmed COVID-19 cases for the City of Detroit, and Wayne, Macomb, Oakland counties between September 1, 2020, and October 4, 2021, were collected from a public data source. The total concentrations of N1 and N2 genes ranged from 714.85 to 7145.98 gc/L and 820.47 to 6219.05 gc/L, respectively, which were strongly correlated with the 7-day moving average of total daily COVID-19 cases in the associated areas, after 5 weeks of the viral measurement. The results indicate a potential 5-week lag time of wastewater surveillance preceding COVID-19 incidence for the Detroit metropolitan area. Four statistical models were established to analyze the relationship between SARS-CoV-2 concentrations in wastewater and COVID-19 incidence in the study areas. Under a 5-week lag time scenario with both N1 and N2 genes, the autoregression model with seasonal patterns and vector autoregression model were more effective in predicting COVID-19 cases during the study period. To investigate the impact of flow parameters on the correlation, the original N1 and N2 gene concentrations were normalized by wastewater flow parameters. The statistical results indicated the optimum models were consistent for both normalized and non-normalized data. In addition, we discussed parameters that explain the observed lag time. Furthermore, we evaluated the impact of the omicron surge that followed, and the impact of different sampling methods on the estimation of lag time.

Sociodemographic characteristics and cervical cancer survival in different regions of the United States: a National Cancer Database study.

OBJECTIVE: To determine how sociodemographic factors impact cervical cancer survival in different geographic locations in the USA. METHODS: A retrospective cohort of patients with cervical cancer from January 1, 2004 to December 31, 2015 in the National Cancer Database (NCDB) was identified. Tumor characteristics as well as race, income, insurance type, and treating facility types were compared among nine geographic regions. χ2 tests and Cox regression were used to compare differences between regions; p values <0.05 were considered significant. RESULTS: A total of 48 787 patients were included. Survival was inferior in seven of nine regions for underinsured patients. In six regions survival was inferior for Medicaid and Medicare patients, respectively: Middle Atlantic: hazard ratio (HR) 1.25 and 1.22; South Atlantic: HR 1.41 and HR 1.22; East North Central: HR 1.36 and HR 1.25; East South Central: HR 1.37 and HR 1.25; West North Central: HR 1.67 and HR 1.42; West South Central: HR 1.44 and HR 1.46. In the Pacific region survival was inferior for Medicare patients (HR 1.35) but not inferior for Medicaid patients. Being uninsured was associated with worse survival in the South Atlantic (HR 1.23), East North Central (HR 1.23), East South Central (HR 1.56), and West South Central (HR 1.31) regions. Annual income level under $38 000 was associated with worse survival in the Middle Atlantic (HR 1.24), South Atlantic (HR 1.35), and East North Central (HR 1.49) regions. Lastly, when compared with academic research institutions, comprehensive community cancer centers had significantly worse survival in four of the nine regions. CONCLUSIONS: Cervical cancer mortality is higher for women with a low income, underinsured (Medicaid or Medicare) or uninsured status, and decreased access to academic institutions in most US regions. An increase in cervical cancer mortality was associated with underinsured or uninsured populations in regions mainly located in the South and Midwest.

"Finding a General Surgeon: Self-Referral in the Digital Era".

BACKGROUND: As technology becomes more prominent in today's society, more patients turn to the Internet to self-refer for a range of surgical problems. Frequently, patients search a nearby hospital's website in order to find a physician. We hypothesized that the variability in hospital websites would make it difficult for patients to find a general surgeon for their care. METHODS: We used the US News and World Report's Hospital Rankings 2018-2019 for this study. The "Find A Doctor" page within each hospital's website was searched for the following conditions: "hernia" and "gallbladder." Information on all suggested providers was collected, including medical specialty and gender. Descriptive statistics were used to analyze the data. RESULTS: The median number of providers listed in each search was 18 (range: 1-204). For "hernia," general surgeons were not the majority of providers suggested at 12/16 institutions. For "gallbladder," general surgeons were not the majority of providers suggested at 14/16 institutions, and 3/16 institutions did not suggest any. All 16 institutions suggested a strong majority of male providers (range: 62-100% male; median: 83% male). DISCUSSION: Considerable variation exists in the suggestion of medical providers for common general surgical problems among the top academic hospitals. Most notably, general surgeons are not listed as the primary providers for these conditions which they commonly manage. Health systems need to examine how their website suggest providers and ensure that patients can easily find the physician most suitable for their care.

Can patients find an Endocrine Surgeon? How hospital websites hide the expertise of these medical professionals.

BACKGROUND: With information on healthcare providers available on the internet, patient self-referral has become popular. This study serves to evaluate the ease with which patients can locate an Endocrine Surgeon using hospital websites. METHODS: Websites of the 16 top academic hospitals from The US News and World Report's Hospital Rankings for 2018-2019 were accessed. Each "Find A Doctor" page was searched for: "thyroid nodule," "hyperparathyroidism," and "adrenal mass." Data for suggested providers was collected and analyzed. RESULTS: Search results for "thyroid nodule" found Endocrine Surgeons as the predominant providers at 6% institutions, 25% suggested none. For "hyperparathyroidism," 31% institutions suggested a majority of Endocrine Surgeons, 19% suggested none. For "adrenal mass," 25% had Endocrine Surgeons as the predominant providers, 31% suggested none. CONCLUSION: The majority of hospitals did not suggest Endocrine Surgeons as the predominant providers for the queried conditions, demonstrating the challenge patients face in finding an Endocrine Surgeon through hospital websites.

Decreasing opioid use in postoperative gynecologic oncology patients through a restrictive opioid prescribing algorithm.

OBJECTIVE: The objective of this study was to evaluate the impact of a post-surgical restrictive opioid prescribing algorithm (ROPA) in gynecologic oncology patients. METHODS: This cohort study included gynecologic oncology patients undergoing any surgical procedure from 08/2018-7/2019 after implementation of a ROPA. Patients were compared to historical controls managed without a ROPA from 10/2016-9/2017. Patients were educated preoperatively about pain management goals, the ROPA, and opioid disposal. A 4-tiered system was developed to standardize prescriptions at discharge based on surgical complexity and inpatient opioid requirements. Patients were surveyed at their postoperative visit to assess home opioid use and satisfaction. Statistical analysis was performed using SPSS Statistics v.24. RESULTS: 2549 patients met inclusion criteria; 1321 in the historical control group and 1228 in the ROPA group. Demographics, including age, BMI, and performance status were similar. Compared with the control group, the average number of opioid pills prescribed was significantly lower in the ROPA group (30.5 vs 11.3; p < 0.001) along with the morphine milligram equivalents (MME) (152.5 MME vs. 83.3 MME; p < 0.001). The percentage of patients requiring opioid refill within 30 days was similar (13.0% vs. 12.6%; p = 0.71). 95.7% of patients surveyed were satisfied with their pain regimen. The total number of pills prescribed annually decreased from 34,130 in the control group to 13,888 in the ROPA group. CONCLUSIONS: A restrictive prescribing practice allows for a significantly lower number of opioids to be prescribed to postoperative patients while maintaining patient satisfaction. There was no increase in opioid refill requests using a ROPA in patients undergoing surgery.

The financial impact of an enhanced recovery after surgery (ERAS) protocol in an academic gynecologic oncology practice.

OBJECTIVE: To determine the financial impact of an enhanced recovery after surgery (ERAS) protocol in gynecologic oncology patients. METHODS: This study identified gynecologic oncology patients who were placed on the ERAS protocol after elective laparotomy from 10/2016-6/2017. A control group was identified from the year prior to ERAS implementation. Financial experts assisted in procuring data for these patient encounters, including payer status, direct and indirect costs, contribution margin, and length of stay (LOS). SPSS Statistics v. 24 was used for statistical analysis. RESULTS: 376 patients met criteria for inclusion: 179 in the ERAS group and 197 in the control group. Patient demographics were similar between the two cohorts. Payer status across the groups was not statistically significant in patients with private insurance (control 43.7% vs. ERAS 41.3%), Medicare (38.1% vs. 31.8%), or self-pay patients (12.2% vs. 15.1%). There was a significantly higher number of Medicaid patients in the ERAS group (6.1% vs. 11.7%; p = 0.05). Hospital direct costs ($5596 vs. 5346) and indirect costs ($5182 vs. $4954) per encounter were similar between groups. However, overall contribution margin per encounter decreased in the ERAS group ($11,619 vs. $8528; p = 0.01). LOS was significantly lower in the ERAS group (4.1 vs. 2.9 days; p = 0.04). CONCLUSIONS: Implementation of the ERAS protocol in gynecologic oncology patients does not lead to increased costs for the patient or hospital system. The decreased contribution margin is likely due to a reduction in per diem payments caused by the reduction in LOS. On a per-patient-day basis, contribution margin was the same for both groups ($2877 vs $2857). The reduction in LOS also created capacity for additional cases, the financial impact of which was not evaluated.

Scalable Synthesis of Orthogonally Protected ß-Methyllanthionines by Indium(III)-Mediated Ring Opening of Aziridines.

Lantibiotics are a class of peptide antibiotics with activity against most Gram-positive bacteria. Lanthionine (Lan) and ß-MeLan are unusual thioether-bridged, non-proteinogenic amino acids, which are characteristic features of lantibiotics. In this paper, we report the facile stereoselective synthesis of ß-methyllanthionines with orthogonal protection by nucleophilic ring opening of aziridines. This method leads to an expedient access to ß-methyllanthionines and allows production of over 30 g of ß-methyllanthionine in a single batch.

Factors Associated With the Highest and Lowest Cited Research Articles in Urology Journals.

OBJECTIVE: To determine what factors of published urology research articles are associated with future citations. METHODS: We identified all primary research articles published between 1997 and 2007 in Journal of Urology, British Journal of Urology International, Urology, and European Urology. Only 50 articles in this period had accrued 0 or 1 citation in a 10-year period following publication. We compared the characteristics of the articles in the low citation cohort to the 50 articles with the highest number of citations from the same journals and time period. Student's t tests, Wilcoxon rank-sum tests, chi-squared tests, and Fisher's exact tests were used to analyze the data with predetermined level of significance set to P < .05. RESULTS: There were many significant differences between the 2 cohorts. When compared to the cohort of articles with 0 or 1 citation, highly cited articles were significantly more likely to be a clinical study, multi-institutional and multinational effort, and related to the field of urologic oncology. They were also significantly more likely to have a larger sample size, a statistically significant primary finding, more authors, more references, and more tables, as well as longer title, abstract, and overall manuscript word counts. CONCLUSION: Very few articles published in the major urology journals accrued 0 or 1 citation over a 10-year period. This suggests that the vast majority of articles selected for publication are used for further future research. Nevertheless, there were distinct differences between the 2 cohorts, showing that certain factors are associated with articles being cited more frequently.