Evaluation of real-time polymerase chain reaction for the diagnosis of protozoal myeloencephalitis in horses using cerebrospinal fluid.

BACKGROUND: Equine protozoal myeloencephalitis (EPM) caused by Sarcocystis neurona remains an antemortem diagnostic challenge in some horses. Recent work suggested the use of real-time PCR (rtPCR) on cerebrospinal fluid (CSF) as a promising diagnostic tool. OBJECTIVE: To evaluate the sensitivity and specificity of S. neurona rtPCR on CSF for EPM diagnosis using horses with EPM and S. neurona-seropositive horses with other neurologic conditions. ANIMALS: Ninety-nine horses with neurologic disease that underwent complete neurologic examination, CSF collection, and, if euthanized, necropsy including the central nervous system (CNS). METHODS: Retrospective case-control study using banked CSF samples. Samples from horses with neurologic abnormalities and necropsy-confirmed EPM diagnosis, presumptive EPM diagnosis using strict criteria (SnSAG2/4/3 ELISA serum:CSF titer ratios <50) and horses diagnosed with other neurologic diseases were used. RESULTS: Fifty-two horses had EPM; 23 were confirmed on necropsy, and 29 were presumptive clinical diagnoses. The other 47 horses all had necropsy-confirmed diagnoses. Four of the 47 horses had normal neurologic findings on necropsy and the remaining 43 horses had neurologic diseases including equine degenerative myeloencephalopathy (EDM), cervical vertebral stenotic myelopathy, trauma, and other miscellaneous conditions. One CSF sample was weakly positive for S. neurona by rtPCR, this sample was obtained from a horse with confirmed EDM. Samples from the other 98 horses were negative for S. neurona by rtPCR. CONCLUSIONS AND CLINICAL IMPORTANCE: Our study contradicts previous conclusions that S. neurona rtPCR is potentially useful for EPM diagnosis, because our results indicate that the assay has a low sensitivity (0%) for EPM.

Jammed solids with pins: Thresholds, force networks, and elasticity.

The role of fixed degrees of freedom in soft or granular matter systems has broad applicability and theoretical interest. Here we address questions of the geometrical role that a scaffolding of fixed particles plays in tuning the threshold volume fraction and force network in the vicinity of jamming. Our two-dimensional simulated system consists of soft particles and fixed "pins," both of which harmonically repel overlaps. On the one hand, we find that many of the critical scalings associated with jamming in the absence of pins continue to hold in the presence of even dense pin latices. On the other hand, the presence of pins lowers the jamming threshold in a universal way at low pin densities and a geometry-dependent manner at high pin densities, producing packings with lower densities and fewer contacts between particles. The onset of strong lattice dependence coincides with the development of bond-orientational order. Furthermore, the presence of pins dramatically modifies the network of forces, with both unusually weak and unusually strong forces becoming more abundant. The spatial organization of this force network depends on pin geometry and is described in detail. Using persistent homology, we demonstrate that pins modify the topology of the network. Finally, we observe clear signatures of this developing bond-orientational order and broad force distribution in the elastic moduli which characterize the linear response of these packings to strain.

Make Your Pitch: A Flexible Assignment for Engaging Students in Aging.

Given trends in local, national, and global demographics, a need exists for educators in fields that serve older adults to provide innovative and engaging assignments that are relevant and applicable to the diverse contexts in which students are likely to find themselves as they pursue their careers. This article discusses a novel "elevator pitch" assignment that could be implemented in a number of ways to fit a variety of pedagogical methods and courses and further tailored to serve the needs of diverse student populations. For those working to actively and successfully recruit, train, and retain students in fields that serve older adults, such flexibility of assignments and delivery are likely to be acutely important as institutions, instructors, and students continue to adapt to rapidly changing developments such as those imposed by the COVID-19 pandemic.

Structured randomness: jamming of soft discs and pins.

Simulations are used to find the zero temperature jamming threshold, φj, for soft, bidisperse disks in the presence of small fixed particles, or "pins", arranged in a lattice. The presence of pins leads, as one expects, to a decrease in φj. Structural properties of the system near the jamming threshold are calculated as a function of the pin density. While the correlation length exponent remains ν = 1/2 at low pin densities, the system is mechanically stable with more bonds, yet fewer contacts than the Maxwell criterion implies in the absence of pins. In addition, as pin density increases, novel bond orientational order and long-range spatial order appear, which are correlated with the square symmetry of the pin lattice.

Food Allergy Management at School.

BACKGROUND: Approximately 8% of schoolchildren in the United States experience potentially life-threatening food allergies. They must diligently avoid allergenic foods and have prompt access to epinephrine to treat anaphylaxis. These prevention strategies must be sustained without interruption, posing a range of challenges at school. METHODS: We conducted semi-structured interviews with 178 participants about their experiences managing food allergies outside the home. Interviews were transcribed and analyzed using an iterative approach in NVivo 10. RESULTS: Participants reported highly varied school experiences across the ecological model. They described the need to be proactive and self-sufficient to manage food allergies. Whereas food allergy-related social exclusion was common, participants also described positive peer interactions, including intensive peer engagement and support. They perceived that formal school policies were limited in scope and inconsistently implemented. Prevention-oriented policies were more common in lower grades than in higher grades. CONCLUSIONS: Poorly defined and implemented policies disrupted students' social and educational experiences at school, families' relationships with school staff, and, ultimately, the safety and wellbeing of students with allergies. Given the high prevalence of food allergies among children, these findings demonstrate the need for multiple layers of support to facilitate safe, socially inclusive food allergy management at schools.

Reconciling opposing perceptions of access to physical activity in a gentrifying urban neighborhood.

OBJECTIVE: We sought to understand perspectives on access to physical activity in a gentrifying neighborhood. DESIGN: This qualitative descriptive study used street intercept interviews and photo documentation. SAMPLE: Participants included members (n = 19) of a gentrifying neighborhood in a northeastern city. RESULTS: Participants held markedly different perceptions of opportunities for physical activity. Some participants, particularly area university students or those who are identified as White, perceived the neighborhood as favorable to physical activity, with high walkability and abundant resources. Other participants, particularly those who identified as Black or African-American, felt it was difficult to be physically active because neighborhood recreation facilities are scarce or unaffordable and parks are poorly maintained or unsafe. Multiple participants noted strategies to overcome neighborhood barriers to physical activity. Regardless of neighborhood perceptions, family and friends played an important role in influencing physical activity. CONCLUSIONS: Nurses must consider how disparities in actual and perceived access to neighborhood resources influence participation in physical activity, particularly in gentrifying neighborhood. Public health nurses are embedded in the neighborhoods that they serve, providing a unique opportunity to understand and address the impact of neighborhood on health.

The association between Medicare accountable care organization enrollment and breast, colorectal, and prostate cancer screening.

BACKGROUND: Despite the rapid diffusion of accountable care organizations (ACOs), the effect of ACO enrollment on cancer diagnosis, treatment, and survivorship remains unknown. The objective of this study was to determine whether Medicare Shared Savings Program (MSSP) ACO enrollment was associated with changes in screening for breast, colorectal, and prostate cancers. METHODS: The authors built a cohort of Medicare beneficiaries from 2006 through 2014 comprising 39,218,652 person-years of observation before and 17,252,345 person-years of observation after MSSP enrollment. The Centers for Medicare & Medicaid Services attribution methodology was recapitulated; and screening services were identified for breast, colorectal, and prostate cancer, implementing both sensitive and specific definitions of cancer screening. Adjusted difference-in-differences analyses were performed using linear regression to characterize changes in annual screening rates after ACO enrollment relative to contemporaneous changes in a non-ACO control group of Medicare beneficiaries. RESULTS: Medicare beneficiaries attributed to ACO-enrolled providers had higher rates of breast, colorectal, and prostate cancer screening before enrollment. A 1.8% relative reduction in breast cancer screening was observed among women attributed to ACO providers (P < .0001), a 2.4% relative increase was observed in colorectal cancer screening (P = .0259), and a 3.4% relative reduction was observed in prostate cancer screening among men attributed to ACO providers (P = .0025) compared with contemporaneous changes in non-ACO controls. CONCLUSIONS: Small-magnitude reductions were observed in breast and prostate cancer screening rates, and a small increase was observed in colorectal cancer screening associated with ACO enrollment. Although ACO enrollment does not appear to drive wholesale changes in cancer screening, small differences may map to meaningful changes in the epidemiology of screen-detected cancers among Medicare beneficiaries.

Does Spending More Get More? Health Care Delivery and Fiscal Implications From a Medicare Fee Bump.

While salient features of the Affordable Care Act include insurance expansions and private coverage reforms, various other provisions are embedded within the law. We focus on a temporary 10 percent fee increase for primary care visits supplied to publicly insured (Medicare) beneficiaries. Using administrative and survey data, we assess the price shock's impact on service volume, physician labor supply, and quality of care. Primary care physicians (PCPs) in independent practices demonstrate, at most, a marginal 2 percent increase in new patient visits while horizontally and vertically integrated PCPs show no change. Both PCP organizational types witness declines in established patient visits, on average, but there is marked heterogeneity: established patient visits increase by 1 to 2 percent among PCPs with fewer Medicare claims in the pre-period. The Medicare fee bump did not observably impact other labor supply outcomes and quality of care margins. We estimate that the policy introduced a $1.5 billion transfer from taxpayers to providers during the initiative's first three years.

Cesarean Delivery Rates and Costs of Childbirth in a State Medicaid Program After Implementation of a Blended Payment Policy.

BACKGROUND: Nearly half of US births are financed by Medicaid, and one-third of births occur by cesarean delivery, at double the cost of vaginal delivery. With the goal of reducing unnecessary cesarean use and improving value, in 2009 Minnesota's Medicaid program introduced a blended payment rate for uncomplicated births (ie, a single facility or professional services payment regardless of delivery mode). OBJECTIVE: We evaluated the effect of the blended payment policy on cesarean use and costs for Medicaid fee-for-service births. METHODS: We identified births in Medicaid Analytic Extract files from 3 years before and after the 2009 payment change in Minnesota and in 6 control states. We used a quarterly interrupted time series approach to assess policy-related changes in study outcomes, comparing Minnesota to control states. Outcomes included cesarean delivery, childbirth hospitalization costs, and maternal morbidity. RESULTS: Minnesota's prepolicy cesarean rate (22.8%) decreased 0.27 percentage points per quarter after the policy for a total decrease of 3.24 percentage points, compared with control states (P=0.01). The cost of childbirth hospitalizations in Minnesota dropped by $425.80 at the time of the policy. Postpolicy, childbirth hospitalization costs continued to decrease in Minnesota relative to prepolicy by $95.04 per quarter, and declined more than control states (P<0.001). There were no significant policy effects on maternal morbidity. CONCLUSIONS: Implementation of a single, blended payment to facilities and clinicians for uncomplicated births mitigated trends toward greater use of cesarean and rising costs of childbirth hospitalization, without adverse effects on maternal morbidity.

Protozoal coinfection in horses with equine protozoal myeloencephalitis in the eastern United States.

BACKGROUND: Infection by 2 or more protozoa is linked with increased severity of disease in marine mammals with protozoan encephalitis. HYPOTHESIS/OBJECTIVES: To assess whether horses with equine protozoal myeloencephalitis (EPM) caused by Sarcocystis neurona also have evidence of infection with Neospora hughesi or Toxoplasma gondii. We hypothesized that horses with EPM would be more likely than horses with cervical vertebral stenotic myelopathy (CVSM) to be positive for antibodies to multiple protozoan parasites. ANIMALS: One hundred one horses with neurologic disease: 49 with EPM and 52 with CVSM. METHODS: Case review. Archived serum and cerebrospinal fluid (CSF) from 101 horses were examined. Inclusion criteria included neurologic disease, antemortem or postmortem diagnosis of EPM or CVSM, and availability of serological results or archived samples for testing. Additional testing for antibodies was performed on serum for T. gondii, as well as serum and CSF for N. hughesi. RESULTS: Horses with EPM were more likely than horses with CVSM to have positive immunologic results for S. neurona on serum (95.9% versus 76.9%, P = .0058), CSF (98.0% versus 44.2%, P < .00001), and serum : CSF titer ratio (91.8% versus 0%, P < .00001). Positive results for Neospora and Toxoplasma were uncommon, with total seroprevalence rates of 12.9% and 14.9%, respectively. The proportions of EPM cases testing positive for Neospora and Toxoplasma (16% and 12%) were not different from the proportions of CVSM cases testing positive (10% and 17%, P = .31 and .47, respectively). CONCLUSION: Results do not indicate an important role for protozoal coinfection in EPM in the eastern United States.

Medicare Accountable Care Organization Enrollment and Appropriateness of Cancer Screening.

Importance: Despite rapid diffusion of Accountable Care Organizations (ACOs), whether ACO enrollment results in observable changes in cancer screening remains unknown. Objective: To determine whether Medicare Shared Savings Program (MSSP) ACO enrollment changes the appropriateness of screening for breast, colorectal, and prostate cancers. Design, Setting, and Participants: For this population-based analysis of Medicare beneficiaries, we used Medicare data from 2007 through 2014 and evaluated changes in screening associated with ACO enrollment using differences-in-differences (DD) analyses. We then performed difference-in-difference-in-differences (DDD) analyses to determine whether observed changes in cancer screening associated with ACO enrollment were different across strata of appropriateness, defined using age (65-74 years vs ≥75 years) and predicted survival (top vs bottom quartile). Main Outcomes and Measures: Rates of breast, colorectal, and prostate cancer screening measured yearly as a proportion of eligible Medicare beneficiaries undergoing relevant screening services. Results: Among Medicare beneficiaries, comprising 39 218 652 person-years before MSSP enrollment and 17 252 345 person-years after MSSP enrollment, breast cancer screening declined among both ACO (42.7% precontract, 38.1% postcontract) and non-ACO (37.3% precontract, 34.1% postcontract) populations. The adjusted rate of decline (DD) in the ACO population exceeded the non-ACO population by 0.79% (P < .001). This decline was most pronounced among elderly women (-2.1%), with minimal observed change among younger women (-0.26%). Baseline colorectal cancer screening rates were lower than those for breast cancer among both ACO (10.1% precontract, 10.3% postcontract) and non-ACO (9.2% precontract, 9.1% postcontract) populations. We observed an adjusted 0.24% (P = .03) increase in screening associated with ACO enrollment, most pronounced among younger Medicare beneficiaries (0.36%). For breast and colorectal cancer, we observed statistically significant differences in estimates of effect between age strata, suggesting that the ACO effect on cancer screening is mediated by age (DDD for both P < .001). Prostate cancer screening declined among ACO (35.1% precontract, 28.5% postcontract) and non-ACO (31.2% precontract, 25.7% postcontract) populations. The adjusted rate of decline in the ACO population exceeded that of the non-ACO population by 1.2%. We observed no difference in estimate of effect between age strata, suggesting that the ACO-mediated changes in prostate cancer screening are similar among younger and elderly men. Results characterizing appropriateness with predicted survival mirrored those when stratified by age. Conclusions and Relevance: Medicare Shared Savings Program ACO enrollment is associated with more appropriate breast and colorectal screening, although the magnitude of the observed ACO effect is modest in the early ACO experience.

Fish Oil Supplementation Does Not Affect Cognitive Outcomes in Cardiac Surgery Patients in the Omega-3 Fatty Acids for Prevention of Post-Operative Atrial Fibrillation (OPERA) Trial.

Background: Cognitive decline has been reported following cardiac surgery, leading to great interest in interventions to minimize its occurrence. Long-chain n-3 (ω-3) polyunsaturated fatty acids (PUFAs) have been associated with less cognitive decline in observational studies, yet no trials have tested the effects of n-3 PUFAs on cognitive decline after surgery. Objective: We sought to determine whether perioperative n-3 PUFA supplementation reduces postoperative cognitive decline in patients postcardiac surgery. Methods: The study comprised a randomized, double-blind, placebo-controlled, multicenter, clinical trial conducted on cardiac surgery recipients at 9 tertiary care medical centers across the United States. Patients were randomly assigned to receive fish oil (1-g capsules containing ≥840 mg n-3 PUFAs as ethyl esters) or placebo, with preoperative loading of 8-10 g over 2-5 d followed postoperatively by 2 g/d until hospital discharge or postoperative day 10, whichever came first. Global cognition was assessed using in-person testing over 30 d with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) (primary outcome), Mini-Mental State Exam (secondary outcome), and Trails A and B (secondary outcome) tests. All end points were prespecified. Statistical methods were employed, including descriptive statistics, logistic regression, and various sensitivity analyses. Results: A total of 320 US patients were enrolled in the Omega-3 Fatty Acids for Prevention of Post-Operative Atrial Fibrillation (OPERA) Cognitive Trial (OCT), a substudy of OPERA. The median age was 62 y (IQR 53, 70 y). No differences in global cognition were observed between placebo and fish oil groups at day 30 (P = 0.32) for the primary outcome, a composite neuropsychological RBANS score. The population demonstrated resolution of initial 4-d cognitive decline back to baseline function by 30 d on the RBANS. Conclusion: Perioperative supplementation with n-3 PUFAs in cardiac surgical patients did not influence cognition ≤30 d after discharge. Modern anesthetic, surgical, and postoperative care may be mitigating previously observed long-term declines in cognitive function following cardiac surgery. This trial was registered at clinicaltrials.gov as NCT00970489.

Focusing on Inattention: The Diagnostic Accuracy of Brief Measures of Inattention for Detecting Delirium.

BACKGROUND: Delirium is frequently missed in most clinical settings. Brief delirium assessments are needed. OBJECTIVE: To determine the diagnostic accuracy of reciting the months of year backwards (MOTYB) from December to July (MOTYB-6) and December to January (MOTYB-12) for delirium as diagnosed by a psychiatrist and to explore the diagnostic accuracies of the following other brief attention tasks: (1) spell the word "LUNCH" backwards, (2) recite the days of the week backwards, (3) 10-letter vigilance "A" task, and (4) 5 picture recognition task. DESIGN: Preplanned secondary analysis of a prospective observational study. SETTING: Emergency department located within an academic, tertiary care hospital. PARTICIPANTS: 234 acutely ill patients who were =65 years old. MEASUREMENTS: The inattention tasks were administered by a physician. The reference standard for delirium was a comprehensive psychiatrist assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. Sensitivities and specificities were calculated. RESULTS: Making any error on the MOTYB-6 task had a sensitivity of 80.0% (95% confidence interval [CI], 60.9%-91.1%) and specificity of 57.1% (95% CI, 50.4%- 63.7%). Making any error on the MOTYB-12 task had a sensitivity of 84.0% (95% CI, 65.4%-93.6%) and specificity of 51.9% (95% CI, 45.2%-58.5%). The best combination of sensitivity and specificity was reciting the days of the week backwards task; if the patient made any error, this was 84.0% (95% CI, 65.4%-93.6%) sensitive and 81.9% (95% CI, 76.1%-86.5%) specific. CONCLUSIONS: MOTYB-6 and MOTYB-12 had very good sensitivities but had modest specificities for delirium, limiting their use as a standalone assessment. Reciting the days of the week backwards appeared to have the best combination of sensitivity and specificity for delirium.

Surgeon Participation in Early Accountable Care Organizations.

OBJECTIVE: We aimed to characterize the landscape of surgeon participation in early accountable care organizations (ACOs) and to identify specialty-, organization-, and market-specific factors associated with ACO participation. BACKGROUND: Despite rapid deployment of alternative payment models (APMs), little is known about the prevalence of surgeon participation, and key drivers behind surgeon participation in APMs. METHODS: Using data from SK&A, a research firm, we evaluated the near universe of US practices to characterize ACO participation among 125,425 US surgeons in 2015. We fit multivariable logistic regression models to characterize key drivers of ACO participation, and more specifically, the interaction between ACO affiliation and organizational structure. RESULTS: Of 125,425 US surgeons, 27,956 (22.3%) participated in at least 1 ACO program in 2015. We observed heterogeneity in participation by subspecialty, with trauma and transplant reporting the highest rate of ACO enrollment (36% for both) and plastic surgeons reporting the lowest (12.9%) followed by ophthalmology (16.0%) and hand (18.6%). Surgeons in group practices and integrated systems were more likely to participate relative to those practicing independently (aOR 1.57, 95% CI 1.50, 1.64; aOR 4.87, 95% CI 4.68, 5.07, respectively). We observed a statistically significant interaction (P <0.001) between surgical specialty and practice organization. Model-derived predicted probabilities revealed that, within each specialty, surgeons in integrated health systems had the highest predicted probabilities of ACO and those practicing independently generally had the lowest. CONCLUSIONS: We observed considerable variation in ACO enrollment among US surgeons, mediated at least in part by differences in practice organization. These data underscore the need for development of frameworks to characterize the strategic advantages and disadvantages associated with APM participation.

Physician Competition in the Era of Accountable Care Organizations.

OBJECTIVE: To calculate physician concentration levels for all U.S. markets using detailed data on integration and accountable care organization (ACO) participation. DATA SOURCE: 2015 SK&A office-based physician survey linked to all commercial and public payer ACOs. STUDY DESIGN: We construct three separate Herfindahl-Hirschman Index (HHI) measures and plot their distributions. We then investigate how prevailing levels of concentration change when incorporating more detailed organizational features into the HHI measure. PRINCIPAL FINDINGS: Horizontal and vertical integration strongly influences measures of physician concentration; however, ACOs have limited impact overall. ACOs are often present in competitive markets, and only in a minority of these markets do ACOs substantively increase physician concentration. CONCLUSIONS: Monitoring ACO effects on physician competition will likely have to proceed on a case-by-case basis.

Cardiac rehabilitation and readmissions after heart transplantation.

BACKGROUND: Exercise-based cardiac rehabilitation (CR) is under-utilized. CR is indicated after heart transplantation, but there are no data regarding CR participation in transplant recipients. We characterized current CR utilization among heart transplant recipients in the United States and the association of CR with 1-year readmissions using the 2013-2014 Medicare files. METHODS: The study population included Medicare beneficiaries enrolled due to disability (patients on the transplant list are eligible for disability benefits under Medicare regulations) or age ≥65 years. We identified heart transplant patients by diagnosis codes and cumulative CR sessions occurring within 1 year after the transplant hospitalization. RESULTS: There were 2,531 heart transplant patients in the USA in 2013, of whom 595 (24%) received Medicare coverage and were included in the study. CR utilization was low, with 326 patients (55%) participating in CR programs. The Midwest had the highest proportion of transplant recipients initiating CR (68%, p = 0.001). Patients initiating CR attended a mean of 26.7 (standard deviation 13.3) sessions, less than the generally prescribed program of 36 sessions. Transplant recipients age 35 to 49 years were less likely to initiate CR (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.23 to 0.66, p < 0.001) and attended 8.2 fewer sessions (95% CI 3.5 to 12.9, p < 0.001) than patients age ≥65 years. CR participation was associated with a 29% lower 1-year readmission risk (95% CI 13% to 42%, p = 0.001). CONCLUSIONS: Only half of cardiac transplant recipients participate in CR, and those who do have a lower 1-year readmission risk. These data invite further study on barriers to CR in this population.

Osteoclast inhibitor treatment among men with metastatic castration-resistant prostate cancer.

BACKGROUND: National Comprehensive Cancer Network guidelines recommend monthly osteoclast inhibitor treatment (OIT) in men with metastatic castration-resistant prostate cancer (mCRPC) to prevent skeletal related events (SREs). We assessed adherence to guidelines by quantifying treatment for SRE prevention in a population-based cohort of men with mCRPC. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data, we identified men aged >65 with prostate cancer as a primary cause of death during 2006-2010. We assessed OIT during a 12-month period between 15 and 3 months before death and used multivariable negative binomial regression to identify factors associated with treatment. RESULTS: Among 9,634 men who died of prostate cancer, 22% received ≥ 1 OIT, and use increased slightly over time. Men age 75-84 and ≥ 85 were less likely than younger men to be treated (IRR 0.63, 95% CI 0.49-0.78 and IRR 0.34, 95% CI 0.17-0.50, respectively). African American men were less likely than white men to receive OIT (IRR 0.75, 95% CI 0.54-0.95), as were men from areas with lower median income (P=0.014). Compared with men seeing a urologist only, men seeing a medical oncologist and a urologist (IRR 2.52, 95% CI 2.36-2.68) or a medical oncologist alone (IRR 3.82, 95% CI 3.54-4.09) had higher incidence rates of treatment. CONCLUSIONS: Fewer than a quarter of American men dying of prostate cancer received recommended treatment to prevent SREs within the final year of their lives, with particularly low rates of treatment among older men, African American men, and those living in areas with low median income. Visits with a medical oncologist were associated with increased use. Further evaluation of these disparities by age, race and socioeconomic status are necessary to identify interventions to reduce them.

The influence of provider characteristics and market forces on response to financial incentives.

OBJECTIVES: Alternative payment models, such as accountable care organizations, use financial incentives as levers for change to facilitate the transition from volume to value. However, implementation raises concerns about adverse changes in market competition and the resultant physician response. We sought to identify physician characteristics and market-level factors associated with variation in response to financial incentives for cancer care that may ultimately be leveraged in risk-shared payment models. STUDY DESIGN: Retrospective cohort study of physicians providing minimally invasive bladder cancer procedures to fee-for-service Medicare beneficiaries. METHODS: We examined the relationship of between-group differences in market-level factors (competition [Herfindahl-Hirschman Index (HHI)] and provider density) and physician-level factors (use of unique billing codes, number of billing codes per patient, and competing financial interest) to responsiveness to financial incentives. RESULTS: Incentive-responsive providers had increased odds (odds ratio [OR], 1.19; 95% CI, 1.04-1.35) of practicing in markets with the highest quartile of provider density but not HHI (OR, 0.96; 95% CI, 0.87-1.05). Incentive-responsive providers were more likely to bill in the highest quartile for unique codes (OR, 1.49; 95% CI, 1.32-1.69) and codes per patient (OR, 1.18; 95% CI, 1.11-1.25) and less likely to have a competing financial interest (OR, 0.76; 95% CI, 0.72-0.81). CONCLUSIONS: Responsiveness to financial incentives in cancer care is associated with high market provider density, profit-maximizing billing behavior, and lack of competing financial ownership interests. Identifying physicians and markets responsive to financial incentives may ultimately promote the successful implementation of alternative payment models in cancer care.

IL-6 variant is associated with metastasis in breast cancer patients.

INTRODUCTION: Although tumor metastases remain significant drivers of mortality, the genetic factors that increase the risks of metastases are not fully identified. Interleukin 6 (IL-6) has emerged as an important factor in breast cancer progression with IL-6 single nucleotide polymorphism (SNP) variants shown to affect survival. We hypothesized that SNPs of the IL-6 promoter at rs1800795 in breast cancer patients are associated with distant metastases. METHODS: We performed an initial case-control study using Vanderbilt University Medical Center's BioVU, a genomic biobank linked to de-identified electronic medical records in the Synthetic Derivative database, to identify germline SNPs that may predict the development of metastatic disease to any site from any solid tumor including breast cancer. We identified a SNP in IL-6: rs1800795 to be of significance and evaluated this finding using a separate, matched-pair cohort of breast cancer patients with and without metastases from The Ohio State University Wexner Medical Center. RESULTS: The initial study suggested that GG relative to CG at rs1800795 (OR 1.52; 95% CI 1.14-2.02; p = 0.004) was significantly associated with the development of metastases. This association was also observed in the Ohio State University cohort (OR 2.23; 95% CI 1.06-4.71; p = 0.001). There were no significant relationships between rs1800795 status and any patient or tumor characteristics, including estrogen receptor status. CONCLUSIONS: These findings suggest that GG SNP at IL-6: rs1800795 may indicate an increased risk of metastasis of primary breast cancer. Further studies in larger population sets are warranted as advanced screening and prophylactic intervention might be employed in GG carriers.

Phosphorylated neurofilament H (pNF-H) as a potential diagnostic marker for neurological disorders in horses.

The current study aimed at the investigating the potential use of phosphorylated neurofilament H (pNF-H) as a diagnostic biomarker for neurologic disorders in the horse. Paired serum and cerebrospinal fluid (CSF) samples (n=88) and serum only (n=30) were obtained from horses diagnosed with neurologic disorders and clinically healthy horses as control. The neurologic horses consisted of equine protozoal myeloencephalitis (EPM) (38 cases) and cervical vertebral malformation (CVM) (23 cases). Levels of pNF-H were determined using an ELISA. The correlation between CSF and serum concentrations of pNF-H was evaluated using Spearman's Rank test and the significance of the difference among the groups was assessed using a nonparametric test. Horses had higher pNF-H levels in the CSF than serum. Horses afflicted with EPM had significantly higher serum pNF-H levels in comparison to controls or CVM cases. The correlation between CSF and serum pNF-H levels was poor in both the whole study population and among subgroups of horses included in the study. There was significant association between the likelihood of EPM and the concentrations of pNF-H in either the serum or CSF. These data suggest that pNF-H could be detected in serum and CSF samples from neurologic and control horses. This study demonstrated that pNF-H levels in serum and CSF have the potential to provide objective information to help in the early diagnosis of horses afflicted with neurologic disorders.