To enable delivery of high quality patient-centered care, as well as to allow primary care health systems to allocate appropriate resources that align with patients’ identified self-management problems (SM-Problems) and priorities (SM-Priorities), a practical, systematic method for assessing self-management needs and priorities is needed. In the current report, we present patient reported data generated from Connection to Health (CTH), to identify the frequency of patients’ reported SM-Problems and SM-Priorities; and examine the degree of alignment between patient SM-Priorities and the ultimate Patient-Healthcare team member selected Behavioral Goal.CTH, an electronic self-management support system, was embedded into the flow of existing primary care visits in 25 primary care clinics and was used to assess patient-reported SM-Problems across 12 areas, patient identified SM-Priorities, and guide the selection of a Patient-Healthcare team member selected Behavioral Goal. SM-Problems included: BMI, diet , physical activity, missed medications, tobacco and alcohol use, health-related distress, general life stress, and depression symptoms. Descriptive analyses documented SM-Problems and SM-Priorities, and alignment between SM-Priorities and Goal Selection, followed by mixed models adjusting for clinic.446 participants with ≥ one chronic diseases  participated. On average, participants reported experiencing challenges in 7 out of the 12 SM-Problems areas; with the most frequent problems including: BMI, aspects of diet, and physical activity. Patient SM-Priorities were variable across the self-management areas. Patient- Healthcare team member Goal selection aligned well with patient SM-Priorities when patients prioritized weight loss or physical activity, but not in other self-management areas.Participants reported experiencing multiple SM-Problems. While patients show great variability in their SM-Priorities, the resulting action plan goals that patients create with their healthcare team member show a lack of diversity, with a disproportionate focus on weight loss and physical activity with missed opportunities for using goal setting to create targeted patient-centered plans focused in other SM-Priority areas. Aggregated results can assist with the identification of high frequency patient SM-Problems and SM-Priority areas, and in turn inform resource allocation to meet patient needs.NCT01945918.ClinicalTrials.gov ID:  Managing a chronic health condition, like type 2 diabetes, requires many ongoing patient activities occurring in parallel, e.g., eating a healthy diet, regular physical activity, and taking medications as directed , 2. The Self-Management Support (SMS) refers to the process of education and support provided to people with chronic health conditions and their families to help them understand their central role in managing their disease, to make informed decisions about care, and to engage in healthy behaviors –9. Whilewww.conntectiontohealth.org to learn more). Thus, CTH provides a useful method for gathering information from patient cohorts about disease self-management in primary care. Such information can be useful for identifying high frequency self-management problems and patient priority areas, and in turn inform needs for adequate resources and care plans to address these needs and priorities.To enable delivery of high quality patient-centered care, as well as to allow primary care health systems to allocate appropriate resources that align with patients’ identified self-management problem areas and priorities, a practical, systematic method for assessing self-management needs and priorities is needed. Connection to Health (CTH) is an electronic SMS system for primary care that addresses these problems by recording patients’ self-management problems and challenges across a range of areas, assessing patient priorities, and facilitating structured action planning and follow-up through a process of shared goal setting  Which areas of self-management do patients with chronic disease report the most difficulty?, (2) Which areas of self-management do patients tend to prioritize for behavior change? (3) Which areas of self-management do patients and Healthcare team members ultimately select as goals or targets of behavior change? (4) To what extent do these goals align with initial patient priorities?cluster-randomized trial to evaluate strategies for implementing CTH in diverse primary care practices.This report focuses exclusively on the patient-reported health assessment and priority-based goal setting data collected as part of a three-arm, Twenty five primary care practices, 13 in Colorado and 12 in Northern California participating in the CTH study were randomized to the two study arms utilizing the electronic CTH program. Inclusion criteria for practices were family medicine or general internal medicine practices with a minimum of 80 patients with T2DM. A diverse set of practices of various sizes and organizational structures were recruited . Practices participated for 18 months, with participation encompassing December 2013 to March 2017 .The CTH program guides patients and members of the healthcare team through the following steps Fig. : (1) patGiven the overall aims of the larger study, clinics generally focused on working with patients with type 2 diabetes, although they were also encouraged to utilize CTH with patients diagnosed with other chronic illnesses. There were no patient eligibility criteria. As part of the study design, all practice members (clinicians and staff) participated in two hours of training including an introduction to SMS and an interactive tutorial on the CTH system including a practice dyad using the summary report and engaging in goal setting. Practices selected the subset of healthcare team members to use CTH in patient encounters. The majority (> 90%) of those team members identified as community health workers (CHWs), health educators, panel managers, chronic care managers, volunteers, or similar roles; while a small portion identified as a nurse or Certified Diabetes Educator (CDE) or primary care physician. The research protocol was approved by the University of Colorado at Denver and the University of California, San Francisco institutional review boards who waived any patient consent given the data presented were collected and used at the point of care and provided to the research team in de-identified form.Congruent with policy recommendations from the Society of Behavioral Medicine , the CTHt tests, as appropriate, tested for differences between completers of priority and goal setting versus non-completers and associations with patient characteristics. Frequencies of SM-Priorities were examined contingent upon the presence of a SM-Problem in that area. Goals selected during action planning were examined in cross-tabs to document frequency of agreement. Generalized Linear Mixed Models (GLMM) examined frequencies adjusting for clustering by clinic as well as patient characteristics associated with the outcomes of interest. Sensitivity analyses using mixed models examined select planned patient subgroups for select common chronic diseases with the same adjustment factors. Data were analyzed using SPSS v.19 software.Descriptive statistics were computed to review item and scale distributions and frequencies by health area. Chi-square tests or n = 18; 72%), with remaining split between independent practices or practices that were part of an integrated healthcare system; and 16 (64%) had achieved NCQA PCMH recognition. Clinics employed on average 6.8 (+ 3.7) FTE clinicians and served 37% (+ 20%) patients on Medicaid.The majority of the 25 participating clinics were Community Health Centers . Participants were on average 55.4 (+ 12.6) years of age, 58.5% were female, and 52.6% had an education level < a high school diploma (Table n = 336) prioritized one (n = 85) or two (n = 251) areas of self-management to discuss with their healthcare team (SM-Priorities). Of these, 74.7% (n = 227) went on to select a self-management goal and to create an action plan for change. Key reasons reported by member of the healthcare team for patients not completing action plans were clinic-based – primarily insufficient time due to work flow. There were no significant differences between patients who did not prioritize health areas or did not create an action plan compared to those who did on the basis of any assessed patient characteristic, reported health condition, or type of self-management need.A total of 446 patients across the 25 clinics completed the health assessment  areas of need for change (red) and 1.2 (+ 1.0) areas of moderate need for change (yellow). No patients reported zero SM-Problem areas, and only 1.3% reported one SM-Problem area. Thus, the average number of reported problem areas per patient was quite high.Of the 12 SM-Problem areas, on average patients reported 6.0 , almost all (96%) went on to create an action plan goal specifically targeting their weight or a behavior intended to directly result in weight loss . Patient SM-Priorities of physical activity (n = 51) were also frequently translated into action plans that focused on physical activity (56.7%). However, concordance between patient SM-Priorities and their ultimate action plan goals was considerably lower for the remaining SM-Problem areas , high levels of alcohol use (10.4 and 7.3% vs. 33.3% p < .001), and tobacco use . In addition, stress was elevated for the 19–39 year old (58.8%) and 40–64 year old groups (56.2%) relative to the oldest age group . Adjusting for clustering by clinic and patient age, virtually identical results were found for the frequency of SM-Problems, SM-Priorities, and degree of alignment with Goals. Likewise, analyses limited to each of the three most common chronic illnesses  yielded similar results.There was no consistent pattern of association between any of the recorded patient demographic factors  and the measures of interest including the frequency of SM-Problems and SM-Priorities or alignment between SM-Priorities and Goal selection with the exception of patient age. Compared to older adults , younger adults (19–39 years) were more likely to report SM-Problems including: missed medications  , 36. PatThe current findings suggest that patients with chronic disease in primary care are able to report on their self-management behaviors and to prioritize them among their often competing self-management problems or areas of challenge. In aggregate, this type of data can assist with the identification of high frequency patient SM-Problems and SM-Priority areas, and in turn to inform resource allocation as well as opportunities to better understand why patients generally are not viewing specific SM-Problems as a priority. Second, findings comparing ultimate goal selection to SM-Priorities illustrate areas of alignment vs. potential misalignment and missed opportunities for using goal setting to create targeted patient-centered plans. The lopsided use of goal setting for the inter-related areas of weight loss, diet, and physical activity is not surprising given the roots of action planning that have traditionally focused on these behavioral lifestyle elements . HoweverViewing patients’ SM-Problems, SM-Priorities and ultimate goal selection together, several notable patterns emerge. Weight loss and physical activity emerged as the most common areas of patient SM-Problems, with high rates of patient SM-Prioritization and translation into action plan goals. This concordance, however, did not extend beyond these two areas: in contrast, health-related distress, conceptually distinct from depression and more closely tied with chronic disease health outcomes , 39, wasPatient-reported SM-Priorities were in general distributed across the self-management tasks, highlighting the diversity of patient needs. Patients’ selection of SM-Priorities among their SM-Problems might have been influenced by multiple factors related to: (1) individual preferences and/or, (2) perceptions of their healthcare team. Other potential explanations were offered by a recent patient advisory group from five participating primary care clinics. They suggested that patients may be more likely to prioritize a given SM-Problem if they view it as: relatively easy or realistic to tackle, important, particularly pressing, comfortable to discuss, and/or something they have been told or think they “should” work on. Additional contributing patient perceptions of healthcare teams factors may include: patient comfort with the healthcare team member, patient viewing the healthcare team member as competent or potentially positioned to assist given their role or experience, or an area the patient believes is a clinician/healthcare team priority.Patient centered care and evidence in support of shared decision making emphasizes the importance of patients’ input and voice in care discussions , 13. TheThe current study has multiple strengths, including a diverse set of health care settings, a diverse group of patients, and a comprehensive yet pragmatic assessment of patient SM-Problems and SM-Priorities. Nonetheless, several limitations are noteworthy. First, patients within clinics were not randomly selected, such that there may have been some bias within clinics regarding patient selection. Second, all variables, including chronic disease status and BMI, were limited to self-report. Confirmation using laboratory and chart data deserve further attention. Third, data presented are limited to only the information entered into the non-EHR integrated CTH program. This did not allow access to clinical referrals or documentation of additional discussions or health plans made with other members of the care team.Results of the current study add to our understanding of the multiple and co-occurring SM-Problems and SMS needs that patients along with their healthcare teams s struggle to tackle together. While patients showed great variability in their SM-Priorities regarding self-management tasks, the resulting action plan goals that patients created with their healthcare team member show a striking lack of diversity, with a lopsided focus on weight loss and physical activity at the cost of addressing a diversity of other important patient-reported SM-Problems. There are many reasons why patient SM-Priorities are not ultimately selected as the focus on action plans and further work is needed to understand the likely multifaceted reasons from both patients’ and healthcare team members’ perspectives.


Low phosphorus availability is a major abiotic factor constraining wheat growth. The molecular mechanisms of the wheat whole genome under low-phosphorus stress are still unclear. To obtain information on gene expression in wheat seedlings under low-phosphorus stress, transcriptome sequencing was performed on roots and leaves. The results showed that 2,318  transcripts were differentially expressed in the leaves, and 2,018  were differentially expressed in the roots. Further analysis showed that these differentially expressed genes (DEGs) were mainly enriched in carbon fixation in photosynthetic organs and in carbon metabolism, photosynthesis, glyoxylate and dicarboxylate metabolism and plant-pathogen interaction in both leaves and roots. These pathways were mainly associated with environmental adaptation, energy metabolism and carbohydrate metabolism, suggesting that the metabolic processes were strengthened in wheat seedlings under low-phosphorus stress and that more energy and substances were produced to resist or adapt to this unfavourable environment. This research might provide potential directions and valuable resources to further study wheat under low-phosphorus stress. Though abundant in soil, it is often limited for plants due to its low bioavailability3. Low-phosphorus stress seriously restricts crop growth and reduces the yield of crops5. To obtain high yields, excessive quantities of P-fertilizer are applied by farmers. Unfortunately, crops can only utilize up to 30% of inorganic phosphate (Pi) from fertilizers because the inaccessible forms are formed from its reaction with iron-aluminium oxides and calcium carbonate compounds7. The remaining phosphorus is fixed in the soil or transferred to groundwater, lakes and oceans through farmland drainage and surface runoff, leading to water eutrophication and algal blooms9. Understanding the molecular mechanism of crops’ responses to low-phosphorus stress and improving their phosphorus use efficiency is an important means to solve these problems.Phosphorus (P) is an essential macronutrient for plant growth and development and plays a key role in the regulation of energy metabolism and the synthesis of nucleic acids and membranes11. Some studies have been conducted on plant responses to low-phosphorus stress. In barley (Hordeum vulgare L.), transcriptome analysis revealed that many genes were significantly upregulated or downregulated in response to low-phosphorus stress, and the DEGs were mainly involved in phosphorus metabolism, such as phospholipid degradation, sucrose synthesis, phosphorylation/dephosphorylation, hydrolysis of phosphoric enzymes and post-transcriptional regulation12. It was also reported that the DEGs were enriched in the oxidation-reduction process, carbohydrate metabolic process, biosynthetic process, and tricarboxylic acid cycle of oat roots under low-P treatment13. To better understand these processes, the DEGs were also investigated under low-phosphorus stress in other crops through transcriptome analysis, such as maize14, rice15, and soybean16. Transcriptome analysis has greatly improved insights into the sophisticated molecular mechanisms regulating phosphorus homeostasis in numerous cultivated crops. However, little research has been conducted on the response of wheat to low-phosphorus stress.Transcriptome profiling using next-generation sequencing technologies can detect the molecular mechanisms of plant responses to abiotic stress17. However, wheat yield is frequently threatened by low-phosphorus stress, especially in acidic and alkaline soils in tropical and subtropical regions19. Therefore, improving the phosphorus use efficiency and biomass yield of wheat under low-phosphorus conditions has great practical significance.Wheat is one of the main cultivated crops in the worldwide food system. To meet the needs of the world’s growing population, the grain yield of wheat must increase at an average annual rate of approximately 2% in a limited area of cultivated landIn this paper, we analysed the wheat responses to low-phosphorus stress using transcriptome analysis. The transcriptome profile will provide more information on the wheat gene sequence related to phosphorus efficiency, and the identification of DEGs following low-phosphorus stress can deepen our understanding of the genetic variation of wheat under low-phosphorus stress and suggest strategies to enhance their phosphorus use efficiency and biomass production with less fertilizer application.Low-phosphorus stress significantly inhibited the growth of wheat seedlings. Under low-phosphorus stress, plant height, shoot dry weight, root dry weight and total root length of wheat seedlings were significantly lower than those of the CK, by 24.76%, 26.75%, 45.66% and 45.10%, respectively  database and the Kyoto Encyclopedia of Genes and Genomes (KEGG) database. GO analysis showed that genes were defined in three major functional categories: molecular function, cellular component and biological process. In total, these unigenes were further classified into 53 and 52 subcategories in the leaves and roots, respectively. Unigenes involved in binding, catalytic activity, membrane, membrane part, intrinsic component of membrane, metabolic process, cellular process and single-organism process in leaves and roots were the most enriched subcategories Fig. .Figure 1The KEGG database was used to identify the metabolic pathways that may be fully or partially represented by annotated coding sequences of unigenes. A total of 18414 unigenes in leaves (9330 unigenes) and roots (9084 unigenes) were assigned to five categories containing 30 KEGG pathways. Among them, carbohydrate metabolism, signal transduction, amino acid metabolism, overview and translation in leaves and roots were the five most strongly represented pathways Fig. .Figure 2p-value < 0.05 were set as the threshold to judge the significance of gene expression differences between low-phosphorus and sufficient-phosphorus conditions. A total of 4336 differentially expressed genes (DEGs) were identified in wheat seedlings under low-phosphorus stress. Among the DEGs, 1,646 genes were upregulated and 672 genes were downregulated in low-phosphorus leaf samples  in pathways categorized into three branches, namely, environmental information processing, metabolism and organismal systems, of which the DEGs enriched in metabolism were dominant. The 20 pathways with the most DEGs involved in the response to low-phosphorus stress in wheat seedlings are shown in Fig. To perform functional classification and analyse the pathway enrichment of DEGs in wheat seedlings under low-phosphorus stress, KEGG pathway enrichment analysis was carried out. In leaves, 848 DEGs were successfully assigned to 158 KEGG pathways. Among them, 37 pathways were significantly enriched  were also among the most enriched in leaves Fig. .To further validate the reliability of the identified DEGs in response to low-phosphorus stress in wheat seedlings, eight genes, including four upregulated and four downregulated genes, were randomly selected from roots and leaves, and their expression in response to low-phosphorus stress was detected by quantitative reverse transcription-PCR (qRT-PCR) analysis. The results showed that there was good consistency between the expression levels of the eight genes analysed by qRT-PCR and their levels detected using RNA-seq Fig. . Consequ21. Reymond et al. pointed out that the primary root length was reduced when Arabidopsis thaliana was grown under low-phosphorus conditions22. In addition, the shoot dry mass of Arabidopsis thaliana grown in a low-phosphorus environment was significantly reduced23. The shoot and root dry matter of chickpea plants were reduced equally when plants were subjected to low phosphorus supply24. In this study, low-phosphorus stress significantly decreased wheat biomass, especially root biomass. The inhibition of root growth led to a decrease in phosphorus adsorption (by 69.28% in comparison to the control). These changes suggest that low-phosphorus stress has a serious impact on wheat seedling growth and phosphorus adsorption.A low-phosphorus or phosphorus-deficient environment has a significant impact on the morphology of plantsPhosphorus stress usually triggers dramatic molecular responses in plants. To gain insight into the molecular response mechanisms involved in low-phosphorus stress in wheat seedlings, RNA-seq analysis was performed. A total of 4,336 DEGs were identified from the whole wheat seedling in response to low-phosphorus stress, including 2,018 DEGs  from roots and 2,318 DEGs  from leaves. These results suggested serious changes in gene expression in wheat seedlings in response to low-phosphorus stress.25. Phosphorus deficiency resulted in significant differences in the expression of genes associated with amino acid and organic acid metabolism in oat26. In addition, many DEGs involved in the process of carbon and energy conversion were identified under low-phosphorus stress28. Enzymes are biocatalysts that control many processes of metabolism, nutrition and energy conversion. Many genes related to enzymes will be activated to resist or adapt to adverse environments during plant growth and development. For example, the peroxidase, phosphate dehydrogenase and malate dehydrogenase genes were upregulated in rice under low-phosphorus stress29. Our study showed that genes related to transferase, oxidoreductase, ammonia-lyase and peroxidase activity were upregulated under low-phosphorus stress, which may provide the necessary material and energy for wheat seedlings to resist or adapt to low-phosphorus stress.GO enrichment analysis showed that the greatest proportion of DEGs were enriched in the category biological process in both leaves and roots of wheat seedlings. DEGs were involved in photosynthesis, amino acid metabolism, organic acid metabolism and carbohydrate metabolism and were expressed highly in wheat seedlings. Many researchers have suggested that differentially expressed transcripts in these processes might play essential roles in plant adaptation to low-phosphorus stress. For example, evidence has shown that a large number of photosynthesis-related genes are differentially expressed in rice under low-phosphorus stressKEGG analysis showed that the DEGs were mainly involved in plant-pathogen interactions, carbon fixation in photosynthetic organisms, glyoxylate and dicarboxylate metabolism, carbon metabolism and photosynthesis in wheat seedlings under low-phosphorus stress. These pathways were also mainly related to environmental adaptation, energy metabolism and carbohydrate metabolism, mostly associated with material circulation and energy transfer. The results showed that the transport of substances and energy might be intensified in wheat seedlings under low-phosphorus stress, and such an adaptation will be significant for wheat’s resistance or adaptation to a low-phosphorus environment. The following discussion highlights some important KEGG pathways that are likely involved in mediating the wheat seedling response against low-phosphorus stress.31. Phosphorus deficiency inhibits photosynthetic activity in plants by changing the photosynthetic phosphorylation process, and inhibition of the photosynthetic phosphorylation process can lead to slow metabolism, thus affecting crop growth and development32. In addition, ATPase and NADPH are involved in plant photosynthesis and play an important role in energy metabolism and material composition. The phosphorus concentration will directly affect their activities34. In this paper, many photosynthesis-related genes were significantly upregulated, including fructose-1,6-bisphosphatase, ferredoxin (Fd), Fd-NADP reductase and ATP synthase, which are involved in the process of photophosphorylation and energy metabolism. The results indicated that some enzymes related to photosynthesis may play an active role in regulating the early response to low-phosphorus stress and triggering the resistance response of wheat seedlings. Surprisingly, in this study, photosynthesis-related genes were identified in the roots of wheat under low-phosphorus stress. Li et al. showed that there are many photosynthesis-related DEGs in rice roots under low-phosphorus conditions25. It has been reported that it may be related to saving energy35, but this response mechanism needs further study.Photosynthesis is an essential part of the life cycle of green plants and provides the necessary energy source for plant metabolism37. We found that many genes involved in glycolysis were significantly upregulated after low-phosphorus stress in this paper, and some were downregulated in wheat leaves, including PFK1 and GAPD3, but the expression of the GAPD3 and PK genes were upregulated in wheat roots. This result suggests that glycolysis was enhanced in roots under low-phosphorus stress and that many energy-producing genes were activated to resist low-phosphorus stress in wheat roots. Some genes that are involved in the TCA cycle were upregulated in leaves and roots, such as malate dehydrogenase (MDH) and isocitrate dehydrogenase (IDH). MDH genes maintaining glutathione were reduced for the functioning of glutathione S-transferase (GST). GSTs may act as binding proteins that sequester flavonoids in the vacuole for protection against environmental stresses38. Therefore, we hypothesized that the upregulated expression of MDH genes may play an important role in protecting wheat from a low-phosphorus environment. Protein phosphorylation occurs in many kinds of amino acids, most of which are serine. Protein phosphorylation plays a major role in signal transduction, is involved in the regulation of nearly all processes within the cell, and enables cells to rapidly respond to environmental changes by controlling the functional properties of proteins in response to external stimuli39. In this paper, we found that many serine-related genes and phosphotransferase genes involved in phosphorylation were upregulated in wheat roots. This result suggests that a low-phosphorus environment induces many phosphorylation-related genes to respond to it and participate in the transmission of stress signals. These data provide a basis for helping future organisms resist or adapt to this environment.Low-phosphorus stress has a certain effect on the expression of genes involved in carbon metabolism in wheat seedlings, especially the expression of genes related to glycolysis, the tricarboxylic acid (TCA) cycle, and the phosphorylation pathway. 6-Phosphofructokinase 1 (PFK1), pyruvate kinase (PK) and glyceraldehyde 3-phosphate dehydrogenase (GAPD3) are key enzymes involved in glycolysis, and the pathways catalysed by PFK1 and PK are irreversible. A previous study showed that genes related to glycolysis, such as PK and GAPD3, were involved in resistance to low-nitrogen and -phosphorus stress41. In addition, changes in the expression of amino acid metabolism genes were observed in sorghum roots, suggesting that these genes can activate the nitrogen uptake and accumulation mechanism under nitrogen deficiency42. Wang et al. showed that some amino acid metabolism genes, including those of glycine, serine and threonine metabolism, were upregulated in oat roots under phosphorus deficiency26. Our research showed that the expression levels of genes related to the glycine, serine and threonine metabolism pathways were significantly upregulated in both wheat leaves and roots in response to low-phosphorus stress, and these genes were mainly related to amino acid metabolism. The differential expression of these genes might play an important role in protecting wheat seedlings from low-phosphorus stress, and we hypothesized that the upregulation of glycine, serine and threonine metabolism genes may also promote phosphorus uptake and accumulation in wheat seedlings.The enhancement of the metabolome could improve the anti-stress ability of the plants, and one analysis of differentially expressed genes showed that serine metabolism under abiotic environmental stimuli was significantly higher than that under a normal growth environment43. To effectively defend against such infections, the mode of innate immunity in molecular pathways has developed in plants44. A previous study showed that once plants are invaded by pathogens, they trigger some proteins to respond to them, and defensive mechanisms are marshalled45. In this paper, many genes belonging to the plant-pathogen interaction pathway were significantly upregulated in both wheat leaves and roots, and these genes were mainly related to calcium-binding protein, calcium-dependent protein kinase and calmodulin. This suggests that some diseases inflict wheat seedlings under low-phosphorus stress and that genes encoding calcium-binding proteins, calcium-dependent protein kinase and calmodulin were activated to enhance the plant-pathogen interaction.Plants are frequently affected by pathogen infections, and stripe rust and scab are common diseases of wheat. Plant pathogens, including bacteria, fungi, oomycetes and viruses, can cause plant diseases; however, a lack of nutrients can also lead to plant diseasesIn conclusion, we conducted a comparative analysis of mRNA expression in roots and leaves of wheat seedlings under low-phosphorus stress by a transcriptomic approach. A total of 2,318 DEGs  were identified in leaves, and 2,018 DEGs  were identified in roots. Further annotation and analysis indicated that DEGs were mainly enriched in five main pathways involved in the wheat seedling response to low-phosphorus stress, which was mainly associated with metabolism processes. This suggests that the metabolism processes were strengthened in wheat seedlings under low-phosphorus stress and that more energy and substances were produced to resist or adapt to this unfavourable environment. These results have expanded our knowledge about the molecular mechanisms active in wheat seedlings under low-phosphorus stress, which will provide potential directions and valuable resources for further research on the wheat response to this stress.Triticum aestivum L.) cultivar was our first choice. WM 52, the breeding unit, was from the seed company of Suzhou City, Anhui Province. It was bred by sexual hybridization with Zhengzhou 8329 as a female parent and Wanmai 19 as a male parent. The variety is semi-wintery, and its advantages are high yield, high quality, cold resistance, disease resistance, lodging resistance and drought resistance. WM 52 is a commonly selected wheat variety in Shanghai and is widely planted in other parts of China. Therefore, WM 52 has good representativeness and practical significance as a test material. Wheat seeds were surface-sterilized with 75% ethanol for 1 min and then rinsed 3~4 times with distilled water, soaked in distilled water and germinated in a growth chamber at 25 °C in the dark for 24 h. The uniformly germinated seeds were selected and grown on moistened germination paper in a growth chamber at a day/night temperature of 20/15 °C (12 h photoperiod) with relative humidity of 75% and 3000 lx of light intensity. When seedlings grew to approximately 5 cm high, the seedlings were transplanted into plastic pots filled with improved Hoagland solution46 and were grown afterwards in an incubator at 20/15 °C (day/night) under a 12 h photoperiod until they showed two fully expanded leaves. During the growth period, seedlings were sprayed with distilled water on time.A representative wheat  and low-phosphorus stress . Except for the phosphorus concentration, the other components of the solution under low-phosphorus stress were identical to those of the control. There were 18 seedlings per treatment with three biological replicates. The growth solutions were refreshed every 3 days. After 14 days of treatment under low-phosphorus stress, root and leaf tissues from different treatments were collected and immediately frozen in liquid nitrogen and then stored at −80 °C until RNA extraction.Two-leaf-stage seedlings were transferred to different conditions: phosphorus sufficiency  were de-enzymed at 110 °C for 10 min and dried at 75 °C until their weight remained constant, to calculate the dry weight. A colorimetric method was used for determination of total phosphorus contentTM platform .Total RNA was isolated for tripled biological replicates from the sampled roots or leaves using the Trizol reagent  according to the manufacturer’s instructions. The quantity, quality and integrity of the total RNA were examined using a NanoDrop 1000 spectrophotometer  and an Agilent 2100 Bioanalyzer . Magnetic beads with Oligo (dT) were used to isolate mRNA from the total RNA. The isolated mRNA mixed with the fragmentation buffer was cut into short fragments, and the mRNA fragments were generated into first-strand cDNA using reverse transcriptase and random hexamer primers. After that, second-strand cDNA was subsequently synthesized using first-strand buffer, DNA polymerase I and RNase H. The cDNA fragments were purified and washed with EB buffer for terminal reparation and poly(A) addition. The short fragments were subsequently connected with adapters. The suitable fragments (200 bp) were PCR-amplified for cDNA library construction. The library was sequenced using the Illumina HiSeq48, and the remaining paired-end clean reads were used to map the reference genome (http://www.ensembl.org/index.html) by TopHat 2.To obtain high-quality reads, reads with adaptor sequences, low-quality reads  and ambiguous ‘N’ nucleotides (with a ratio of ‘N’ more than 5%) were removed by the Cutadapt software. After that, a reference genome index was established using Bowtie2 softwarehttp://www.bioconductor.org/packages/release/bioc/html/DESeq.html). An absolute value of log 2FoldChange > 1 and p-value < 0.05 were used as the thresholds to judge the significance of gene expression differences.Read numbers mapped to every gene were counted using HTSeq software. The RPKM (reads per kilobase per million reads) value per gene was calculated according to the gene length and mapped read count. Genes with RPKM > 1 were deemed expressed in the current study. Differential expression between the low-phosphorus and control groups was then analysed using the DESeq R package (http://geneontology.org/) were performed using the Blast2Go program. GO terms and biological pathways against the KEGG database (http://www.genome.jp/kegg) with a p-value < 0.05 were deemed to be significantly enriched in DEG analysis.Gene annotations and functional enrichment analysis, including Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) biological pathways, were used to identify which DEGs from root and leaf tissues after low-phosphorus treatment were significantly enriched in GO terms or biological pathways. Gene annotations against the GO database . Eight differentially expressed genes induced by low-phosphorus stress were randomly selected from roots and leaves for experimental validation (Table RLI (Ta2776) was used as an internal control. Specific primers for real-time PCR were designed by Primer Premier 5.0 software , as shown in Table −△△Ct 49.To confirm the reliability of the RNA-seq results, quantitative real-time PCR (qRT-PCR) was performed using the SYBRon Table . RLI (TaSupplementary Information


Data were analyzed according to OS as well as PSA response patterns with regard to prior therapies, laboratory biomarkers and metastatic extent in univariate as well as multivariate Cox's proportional hazards models. PSA decline was assessed using the lowest PSA levels after the first cycle of therapy  and during the entire observation period (best PSA response).Results: In total, 54 patients (49.5%) died during the observation period. First and second line chemotherapy were performed in 85% and 26%, and Abiraterone and Enzalutamide were administered in 83% and 85%, respectively. Any initial PSA decline occurred in 55% while 25% showed a PSA decline of ≥50%. The median estimated OS was 9.9 months (95% CI: 7.2-12.5) for all patients. Any initial decline of PSA was associated with significantly prolonged OS . Second line cabazitaxel chemotherapy  and presence of visceral metastases  were associated with shorter OS. Only visceral metastases remained significant in a multivariate analysis.Conclusion:177Lu-PSMA-617 is an effective therapy for patients with mCRPC. However, the present data indicate that its beneficial effects on OS are strongly influenced by pretreatment (history of second line chemotherapy with cabazitaxel) and the presence of visceral metastases at onset of 177Lu-PSMA-617 treatment. Prostate-specific membrane antigen (PSMA) ligands are used both for diagnostics and therapy of patients with prostate cancer and are indeed changing the management of prostate cancer patients 177Lu-labelled PSMA-617, has been the subject of various studies during recent years 177Lu-PSMA-617 are the reported low toxicity profile, the high response rates and an improvement in quality of life, even in comparison to other third-line treatments like Cabazitaxel and Enzalutamide 177Lu‑PSMA‑617 therapy may even prolong overall survival (OS) in a heavily pretreated patient cohort. In a previous study, an initial PSA decline of 20.9% after the first 177Lu-PSMA-617 cycle was independently associated with longer OS 177Lu-PSMA-617 and select for optimized therapy sequencing in mCRPC.The most commonly used radiopharmaceutical for patients with advanced metastatic castration- resistant prostate cancer (mCRPC), 177Lu-PSMA-617. To this end, the impact of earlier therapies, such as second-line chemotherapy with Cabazitaxel, are analyzed to further elucidate the factors determining the success of 177Lu-PSMA-617 therapy. It is known that visceral metastases of patients with mCRPC are associated with poor outcome The aim of the present study was to identify factors in addition to PSA response that may help prognosticating OS in patients treated with 177Lu-PSMA- 617 radioligand therapy (RLT) between November 2014 and December 2018 were included in the present retrospective analysis. All patients were castration- resistant and were pretreated with at least one line of chemotherapy (or were not suitable for chemotherapy) as well as at least one of next-generation anti-hormonal therapies . All patients were informed about possible adverse events and risks in detail which may be associated with 177Lu-PSMA-617 therapy. All patients gave their written informed consent prior to treatment. The decision for 177Lu-PSMA therapy was made by the interdisciplinary tumor board after carefully reviewing each individual case. PSMA-RLT is strictly considered last-line therapy after progression or failure of all other therapy options. 26 patients were included in a previous multicenter study A total of 109 patients treated with All procedures performed in this study were done in accordance with ethical standards and according to the 1964 Helsinki Declaration and its later amendments. This study was approved by the local ethics committee .177Lutetium  on site as previously described. RLT injection was performed as already described elsewhere 177Lu-PSMA-617 RLT cycles were administered every 6-8 weeks until tumor progression, death, or withdrawal of the patient's consent.The PSMA-617 precursor was purchased from ABX advanced biochemical compounds  and labelled with 177Lu-PSMA-617 therapy, during further therapy cycles, and during observation period and were analyzed according to their effect on survival.Overall survival of each patient was determined as the primary clinical endpoint and was defined as death from any cause. PSA decline was assessed using the lowest PSA levels after the first therapy cycle  and during the entire observation period (best PSA response). Biochemical response is defined by the Prostate Cancer Working Group 3 (PCWG3) criteria as a PSA decline ≥ 50% Any PSA decline, a decline of ≥ 30 % and a decline of ≥ 50% were used to differentiate subgroups to evaluate the implications on OS . Furthermore, patients were grouped according to whether they had received a second line chemotherapy with Cabazitaxel or not. In an additional approach, patients were grouped according to whether they presented with visceral metastases and compared with regards to OS.2-test was applied to test the relative distribution of visceral metastases between different treatment groups.SPSS Statistics 24  and GraphPad Prism  were used for statistical analysis. Descriptive statistics are reported as medians and IQR for continuous variables and frequencies for categorical variables. To identify parameters with significant impact on OS, multiple baseline and follow-up parameters were assessed by Kaplan-Meier estimates, log-rank tests and Cox proportional hazards ratios (HR) with corresponding 95% confidence interval (95%CI) in a univariate as well as multivariate analysis approach. Chip-values ≤ 0.05 are considered statistically noticeable.To detect significant differences, pairwise comparison of different groups was performed by students t-test using GraphPad Prism 7; 177Lu-PSMA-617 with a median cumulative dose of 18.3 GBq (IQR 5.2 - 58.5) were applied to 109 patients. The median administered single dose was 6.2 GBq (IQR 5.8 - 6.48) with a median of three cycles 177Lu-PSMA-617 given (range one to nine cycles). Due to death or primary disease progression on 177Lu-PSMA-617, 21 patients (19%) received only one cycle of therapy.Patient's characteristics are summarized in table At baseline, 93% of patients presented with bone metastases, 81% had lymph node metastases, and 44% showed visceral metastases. All patients were castration resistant. 85% had received at least one line of chemotherapy (Docetaxel) and 26% had been treated with a second-line chemotherapy with Cabazitaxel. All patients had received at least one line of next-generation anti-hormonal therapy with Abiraterone or Enzalutamide, 85% of whom had been treated with Enzalutamide and 83% with Abiraterone, 79% had received both. 16 patients had not been pretreated with Docetaxel due to contraindication for chemotherapy . In total, 54 patients (49%) died during the observation period.Kaplan-Meier analysis of the entire cohort revealed a median survival of 9.9 months  p = n.s.). An initial PSA decline of ≥50% was associated with prolonged survival  as well as an initial decline of ≥30 % . Like the initial PSA response rates, the analysis of best PSA response rates gave similar results with a decline of ≥30% , but not after multivariate cox regression analysis.Any PSA decline occurred in 61 patients (70%), while 26 patients (30%) presented with PSA level increase. A proportion of 32% responded with a decrease ≥ 50%, 50% responded with a PSA decline ≥30%. Patients with any initial PSA decline after the first cycle of treatment showed a significantly longer OS  was identified to have an impact on OS: Twenty-eight patients 26%) had received second line Cabazitaxel, which was associated with shorter OS compared to patients who had not received second line chemotherapy , while an equal proportion of each group had lung metastases (21 and 22%). To investigate whether Cabazitaxel (CABA) treatment and liver metastases (LM) have effects on survival, we performed an analysis with four groups: LM+CABA+ (n=15); LM-CABA+ (n=13), LM+CABA- (n=19) and LM-CABA- (n=61). Untreated patients (CABA-) without LM showed the longest OS , while CABA treated patients with LM (LM+CABA+) presented with the shortest OS in this comparison . There were no significant differences regarding PSA level or PSA response  of the entire cohort presented with visceral metastases, which was found to be associated with significantly shorter survival  as well as next-generation anti- hormonal therapy and Radium-223on OS was investigated and was not significant (data not shown).177Lu-PSMA-617 RLT and their impact on OS.The present study investigates the role of prior treatment strategies and biochemical parameters, such as PSA, ALP and LDH in 109 patients with mCRPC undergoing 177Lu-PSMA-617 therapy Recent studies have postulated that a PSA response of ≥50% is a critical prognostic factor for OS in patients with mCRPC receiving 177Lu-PSMA- 617 RLT was 20.87% 177Lu-PSMA-617 RLT 20As shown in an earlier study, the present study confirmed that a decline in PSA levels of ≥50%, defined as biochemical response by PCSWG3, was associated with prolonged survival 177Lu-PSMA-617 RLT. In the present cohort, patients treated with 177Lu-PSMA-617 RLT showed a shorter survival when having been pretreated with Cabazitaxel, compared to untreated individuals. The two groups did not vary with regard to PSA at baseline, and PSA response as well as age, ALP and LDH levels at baseline. Furthermore, similar levels of hemoglobin, age, platelets and neutrophil counts, as well as similar performance status of the patients (ECOG and Karnofsky scores (data not shown) were observed. However, noticeably, the metastatic burden was distinctively different in the patients that had been treated with cabazitaxel before. Here, almost twice as many patients had visceral metastasis compared to those patients who were cabazitaxel- naïve. Since chemotherapy is effective in visceral, especially liver metastasis, this may have been part of the reason why cabazitaxel had been given previously. And, despite second line chemotherapy may reduce the tumor burden, however, the remaining metastases may act more aggressively, as indicated by disease progression and earlier death. This might be due to tumor heterogeneity, causing a response of differentiated tumor lesions to therapy, whereas the more aggressive tumor lesions do not respond at all, possibly due to a cabazitaxel resistance. There is evidence that cancer cells of soft tissue metastases such as those sited in the liver might express more survivin and, hence, poorly or not at all respond to apoptosis inducing therapies +CABA+ and 73% of LM+CABA- patients already had died during the observation period, while 46% and 35% of LM-CABA+ and LM-CABA- patients, respectively were still alive at termination of the observation. To face the mortal risk of liver metastases that are low or potentially void of PSMA expression, we propose the investigation of a combined or alternating therapy using 177Lu-PSMA-617 RLT and local liver targeted therapy e.g. selective internal radiotherapy (SIRT) or external radiation The positive effects of Cabazitaxel after other chemotherapeutics, such as Docetaxel, has been investigated in other studies with positive outcomes, such as improvement of health-related quality of life and pain control This study faces a number of limitations due to its retrospective design. Retrospective data collection may have led to incomplete records of possible confounders and therefore overestimation of the reported effects. Moreover, patients in this study have not been selected randomly, but retrospectively enrolled because they fulfill certain predesigned criteria. However, these data have been collected without any hypothesis and purpose which should exclude any systematic bias.177Lu-PSMA-617 is an effective therapy for patients with mCRPC. However, the present data indicate that its beneficial effects on OS are strongly influenced by pretreatment therapeutic strategy (history of second line chemotherapy with cabazitaxel) and the presence of visceral metastases at onset of 177Lu-PSMA-617 treatment. The latter remained the only independent predictor of OS. This warrant focusing on better understanding of sequencing therapies in mCRPC and focal treatment of liver metastases in future studies. Further prospective controlled trials have to confirm these data.


To evaluate the use of YKL-40 in the discrimination between benign and malignant adnexal mass and to determine its prognostic value in assessing residual tumor after primary cytoreduction and platinum sensitivity in serous epithelial ovarian carcinoma (EOC). During the three years from January 2015 to December 2017, a nonconsecutive series of 100 patient  who underwent surgery for an adnexal mass were enrolled in the study. Preoperatively, serum samples were collected for YKL-40 level analysis.YKL-40 [receiver operator characteristics (ROC)-area under curve (AUC)=0.83] was a significantly better predictor of EOC than cancer antigen-125 (ROC-AUC=0.75). Using a cut-off for YKL-40 of 47.7 ng/mL had a sensitivity of 80% and a specificity of 70%. Higher serum YKL-40 levels were associated with advanced stage, higher grade, residual tumor after primary cytoreduction and recurrence. Platinum-sensitive patients had significantly elevated levels of YKL-40 compared with platinum-resistant or refractory patients.The results obtained from our study support the use of serum YKL-40 for the discrimination between malignant and benign ovarian tumors. YKL-40 levels in patients with serous EOC may also predict disease residual disease after primary cytoreduction and recurrence. Further studies are needed to understand the relationship between YKL-40 and platinum sensitivity. PRECIS: YKL-40 may be used in the management of adnexal masses and may predict residual disease after primary cytoreduction and recurrence.. This poor prognosis emphasizes the need for early detection in screening programs and prognostic markers to guide individual cancer treatment. The standard treatment of early epithelial ovarian carcinoma (EOC) is full staging including pelvic and paraaortic lymphadenectomy. Debulking surgery followed by platinum-based chemotherapy is the cornerstone of treatment of advanced EOC. Neoadjuvant chemotherapy followed by interval cytoreduction has been a debatable alternative option. A metaanalysis of 21 non-randomized trials concluded that survival between two groups was similar. Subsequently, Vergote et al. performed a randomized trial including patients with stage IIIC-IV EOC and found that optimal cytoreduction was higher in an interval cytoreduction group compared with a primary cytoreduction group with significantly less morbidity in the interval cytoreduction group. However, a number of studies showed that leaving no residual tumor following primary debulking surgery was the single most important independent prognostic factor in advanced EOC,5. Patients who are at higher risk of residual tumor after primary cytoreduction should be isolated in the preoperative period, and these should benefit from neoadjuvant chemotherapy. A glycoprotein, YKL-40, also known as chitinase-3-like 1 protein, was identified in the 1990s. Since then, it has been of special interest because it is associated with degradation of extracellular matrix and promotes angiogenesis in a vascular endothelial growth factor (VEGF)-independent manner,7. During the last decade, YKL-40 has been increasingly studied in several tumor types,8,9,10. In vitro, YKL-40 upregulates VEGF and is associated with tumor angiogenesis. In vivo animal studies demonstrated that inhibition of YKL-40 decreased angiogenesis, tumor formation, and metastasis,12,13. Recent studies showed that neutrophils and tumour cells expressed and released YKL-40 into the blood,14. Increased serum levels of YKL-40 were shown in some cancer types such as breast cancer, lung cancer, colorectal cancer, melanoma, and endometrial cancer,10,15,16. YKL-40 was suggested to have the potential to be a better marker than cancer antigen-125 (CA-125) for early diagnosis of EOC,18. However, results from recent studies on the diagnostic efficiency of YKL-40 were inconsistent,19,20. There are a limited number of studies reporting that elevated plasma YKL-40 levels are associated with worse outcomes in patients with ovarian cancer,21,22,23. Also, it has been suggested that future studies should focus on determining an optimal cut-off value in patients with ovarian cancer for serum YKL-40. In this study, we aimed to evaluate the usefulness of YKL-40 in the discrimination of benign and malignant adnexal masses and to determine the efficacy of YKL-40 in the preoperative estimation of the prognostic parameters such as stage and grade of the disease, residual tumor after primary cytoreduction, and response to platinum-based chemotherapy.Ovarian cancer is a common gynecologic malignancy associated with poor prognosis worldwide. Patients with early stage ovarian cancer have a 5-year overall survival of 70-90%. However, more than 70% of women are diagnosed as having stage III or IV disease, which has a 5-year survival rate of around only 25%. Blood samples were collected preoperatively from a nonconsecutive series of 100 patients who were planned to undergo surgery for an adnexal mass in our clinic. Exclusion criteria were the presence of one or more of the following: i) a suspicous malignancy other than ovarian cancer; ii) systematic disease including renal and/or hepatic impairment; iii) neoadjuvant chemotherapy; iv) history of any malignancy; v) ovarian malignancy other than serous histopathology; and vi) pregnancy. Frozen section evaluation was performed intraoperatively in the presence of suspicion in the diagnosis. The same gynecologic pathologists evaluated all of the specimens. The stage of disease and histologic types were in accordance with the International Federation of Gynecology and Obstetrics classification. Maximal cytoreduction was defined as removing all gross tumoral tissue with no visible disease left. Optimal cytoreduction was defined as residual volume of 1 cm or less after surgery. Residual tumor more than 1 cm was classified as suboptimal cytoreduction. All patients with serous EOC (except those with stage IA and IB disease) received 6 cycles of adjuvant carboplatinum and paclitaxel. The platinum-free interval was defined as the interval from the last treatment with platinum to recurrence. Patients were accepted as platinum sensitive, if the platinum-free interval was longer than 6 months; platinum resistant, if it was shorter than 6 months; or platinum refractory, if the disease was persistent or progressive during the first-line chemotherapy. Progression of disease was diagnosed in the presence of elevated CA-125 and imaging results according to Response Evaluation Criteria in Solid Tumors criteria. Progression-free survival was defined as the time interval between primary surgery and progression or death from any cause. Blood samples were collected in EDTA-containing tubes and anticoagulant-free tubes after an overnight fast on the morning before the surgery. Plasma and serum were seperated immediately and stored at -80 ºC until analysis. After reaching the desired number of cases in both groups, all serum samples were defrosted at room temperature in the medical biochemistry laboratory of the faculty. Serum YKL-40 concentrations were determined by a commercial enzyme-linked immunosorbent (ELISA) kit using a double-antibody sandwich enzyme immunoassay technique . Each ELISA analysis was performed according to the manufacturer’s instructions. All tests showed intraassay and interassay coefficients of variations below 6% (n=10) and 7.5% (n=10), respectively. The analytical sensitivity of the test was 0.52 ng/mL.This prospective observational study was conducted at İstanbul University Cerrahpaşa Faculty of Medicine, Division of Gynecologic Oncology, between January 2015 and December 2017. The study was approved by the Ethics Committee of İstanbul University Cerrahpaşa Faculty of Medicine (protocol number: 83045809-604.01.02). Written informed consent was obtained from all patients. The manuscript was prepared in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology statementPatients’ characteristics and clinical features were summarized using standard descriptive statistics. Mann-Whitney U test was used for comparison between two groups. T-test was used in comparison of independent samples’ average. Receiver operating characteristics curves (ROC) were constructed for YKL-40 and CA-125 serum concentrations as diagnostics for cancer by plotting sensitivity versus 1-specificity, and area under curve (AUC) was calculated for both markers. All p-values were two sided and p<0.05 were considered as statistically significant. Statistical analyses were performed using SPSS version 21.Age, BMI, and menopausal status were similar between the malignant and benign groups . The patAs illustrated in . For long time, the best documented and the most frequently recommended serum marker has been CA-125 in the management of adnexal masses. In this study, preoperative serum levels of YKL-40 were assessed in patients with benign adnexal mass, and in patients with serous EOC. One of the major findings of this study is that patients with EOC had significantly higher serum YKL-40 levels compared with those with benign ovarian tumors. Moderate-to-high sensitivity and specificity  was found when a cut-off level of 47.7 ng/mL was used. On the other hand, the sensitivity and specificity of CA-125  were 76% and 57.5%, respecitvely. YKL-40 was a better predictor of ovarian cancer than CA-125 in our study population. Similar findings were observed in previous studies. Plasma YKL-40 levels were found to be elevated in more than 70% of patients with ovarian cancer compared with healthy patients,21,22,23. As a result, YKL-40 has been included in the “top 9” biomarkers that are capable of discriminating between malignant and benign ovarian diseases. Secondly, we investigated the association between YKL-40 and prognostic factors of EOC such as stage and grade of disease, residual tumor after primary cytoreduction, and recurrence. Results from similar studies suggested that high preoperative YKL-40 was an independent predictor of worse survival, which is in accordance with our findings,21,22,23. Zou et al. found that YKL-40 was associated with poor clinical outcome and worse tumor stages and grades. A unique study from Copenhagen, investigating the prognostic value of plasma YKL-40 in platinum-resistant ovarian cancer patients treated with bevacizumab found that elevated YKL-40 levels (>95th percentile) at baseline were associated with poor survial and residual disease after primary surgery. Furthermore, two studies found that high serum levels of YKL-40 were associated with chemoresistance,30. On the contrary, higher YKL-40 levels were detected in platinum-sensitive patients in the present study. One possible explanation for the contrast may be that Gronlund et al. examined the role of YKL-40 on chemosensitivity in the second-line treatment of EOC patients, whereas we included only patients with serous EOC who received first-line platinum-based chemotherapy. For the first time, Chudecka-Glaz et al. demonstrated that higher serum YKL-40 levels were associated with first-line platinum resistance. Their study and ours included a limited number of patients. Larger studies are needed to see if there is a correlation between YKL-40 and platinum sensitivity.There are still limited data investigating serum markers to differentiate between benign and malignant ovarian tumors. In our study, all patients with ovarian malignancy had the same histopathology. The present study included patients over a period of almost three years. However, because of the short study period, the same practices  were applied to all patients. The limitations of this study include the small number of patients, which means that strong conclusions cannot be drawn.It has been suggested that future studies of serum YKL-40 should be powered to investigate its value as a biomarker in individual histologic subtypes of ovarian cancerIn conclusion, our findings suggest that preoperative serum YKL-40 can be used for to discriminate between malignant and benign ovarian tumors. In addition, higher YKL-40 levels indicate a higher risk of recurrence. Conflicting results regarding YKL-40 and platinum sensitivity should be eliminated by larger prospective studies.


This population-based cohort study examines treatment patterns for stenosing tenosynovitis (trigger finger) and determines surgeon-level factors associated with adherence to evidence-based treatment. What surgeon characteristics are associated with adherence to the evidence-based cost-effective approach for the treatment of stenosing tenosynovitis (trigger finger)?In this population-based cohort study of 83 667 patients with single-digit trigger finger, 33% of the variation in adherence was associated with surgeon-level characteristics, including specialty type and surgeon volume.These findings suggest that understanding barriers to implementation of evidence-based treatment of trigger finger and improved implementation strategies should be a priority to improve outcomes and reduce costs. Stenosing tenosynovitis (trigger finger) affects approximately 2% of the population. Given the prevalence of trigger finger and rising health care costs, adherence to the cost-effective and evidence-based treatment algorithm will permit better outcomes and allocation of resources.To examine treatment patterns for trigger finger and to determine surgeon-level and patient-level factors that influence adherence to evidence-based treatment.This retrospective population-based cohort study examined deidentified claims for treatment of trigger finger from a national insurance provider using the Clinformatics Data Mart database. Patients were included if they were 18 years or older and treated from January 1, 2002, through December 31, 2016 , with a new diagnosis of single-digit trigger finger. Data were analyzed from December 21, 2018, through April 28, 2019.Cost-effective and evidence-based research published in July 2009 for the treatment of trigger finger.After excluding the 1-year washout period on either side of July 1, 2009, adherence to the recommended treatment algorithm of 2 corticosteroid injections before surgical release of trigger finger was compared with practice before publication of research supporting this cost-effective and evidence-based approach.P = .27). Substantial variation in adherence was observed at the surgeon level . Plastic surgeons had no change in adherence over time compared with orthopedic surgeons , whereas general surgeons had increased adherence . Higher-volume surgeons were also more adherent to these evidence-based recommendations .In this analysis of 83 667 patients with trigger finger, 52 698 (63.0%) were women, and 20 045 (24.0%) had type 1 or 2 diabetes. Mean (SD) age was 61 (13) years. From 2002 to 2016, an overall increasing trend in adherence to the cost-effective and evidence-based approach to treatment was noted, with no significant increase in adherence in the postpublication era (67.5% vs 73.3%; This study found substantial surgeon-level variation in adherence to evidence-based treatment of trigger finger. Surgeon specialty and volume were associated with differences in adherence. Efforts to understand surgeon barriers to implementation, regardless of physician specialty, appear to be necessary, and better implementation strategies may permit increased uptake of evidence-based treatment of trigger finger. Furthermore, recent estimates reveal that only two-thirds of health care payments are based on high-value care.6 Thus, as the United States transitions from fee-for-service to value-based care, defining the lapses in care quality is imperative in health care reform.7Evidence-based practices are associated with better treatment outcomes and patient satisfaction.8 This condition is caused by inflammation and narrowing of the A1 pulley, often resulting in a painful locking and triggering when the finger is flexed.9 The treatment for trigger finger typically consists of corticosteroid injections and/or surgery to release the A1 pulley. Although surgical treatment provides patients with satisfactory outcomes, recent evidence suggests that conservative treatment modalities, specifically corticosteroid injections, should be attempted before surgery.13 In 2009, Kerrigan and Stanwix14 published a cost-minimization analysis to identify the least costly and most effective treatment algorithm for trigger finger. The Medicare reimbursement for a corticosteroid injection was approximately $171, and the cost for surgery ranged from $601 to $1203 depending on location.14 The researchers found that 2 corticosteroid injections before any surgical treatment offered the patients adequate relief while being the least costly option. Subsequent research has reinforced the efficacy of corticosteroid injections for trigger finger and recommendations of 2 injections before release.14 Despite these recommendations, adherence at a national level is not yet known. Given the high prevalence of trigger finger, a comprehensive understanding of the treatment variations may help guide clinical decisions and aid in the allocation of resources for this patient population.Stenosing tenosynovitis (trigger finger) is one of the most common hand conditions, with a prevalence of 2% in the general population.As health care costs in the United States continue to rise, it becomes increasingly important to provide physicians with guidance regarding cost-effective treatment. The purpose of this study is to investigate national adherence to an evidence-based approach for treatment of trigger finger and thereby determine avenues to provide high-value care for these patients. We used a national sample of individuals treated for single-digit trigger finger to examine adherence to the cost-effective treatment algorithm. Our specific objectives are to (1) identify trends of adherence to a commonly accepted and cost-effective treatment algorithm and (2) examine the role of surgeon- and patient-level factors associated with adherence.STROBE) reporting guidelines.We used the Clinformatics Data Mart database (OptumInsight) from January 1, 2002, through December 31, 2016, to conduct our study. Clinformatics Data Mart contains inpatient and outpatient deidentified patient encounters for more than 140 million enrollees covered by private insurance. This study received exempt status from the University of Michigan’s institutional review board, which waived the need to obtain informed consent because the data were deidentified. We followed the Strengthening the Reporting of Observational Studies in Epidemiology  and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis codes  and R, version 3.5.1 .We conducted descriptive analyses of adherence to the evidence-based approach to the treatment of trigger finger. We estimated 95% CIs to investigate trends and variability in visit-level adherence using bootstrap resampling with 500 observations repeated 100 times. We then examined the association between patient- and surgeon-level characteristics with adherence over time. Given the nonrandom clustering of patient visits within surgeons, we used multilevel logistic regression with random intercepts at the surgeon level to assess surgeon-level variation in rates of adherence over time. Fixed slopes were used in the model. The covariates in the model consisted of patient age, a diagnosis of diabetes in the patient, time, surgeon specialty, and surgeon volume and included an interaction for the differential change in adherence by surgeon specialty over time. Model diagnostics revealed a satisfactory model fit. The intraclass correlation was also calculated to determine the percentage of variation at the surgeon level. To support the conclusions of our analysis, we performed a sensitivity analysis excluding all patients with a possibility of multiple trigger finger diagnoses based on A total of 83 667 patients  received treatment for single-digit trigger finger from 2002 through 2016 by 11 120 different surgeons with 110 012 patient visits. The surgeons included 9837 orthopedic surgeons (88.5%), 869 plastic surgeons (7.8%), and 414 general surgeons (3.7%). The median number of procedures performed per surgeon was 3 . Of all patients included in the final cohort, the mean (SD) age in the prepublication era was 57 (12) years compared with 63 (13) years in the postpublication era. In the total cohort, 20 045 (24.0%) had a diagnosis of diabetes. Compared with the prepublication era, an increase in diabetes was seen in the postpublication era (4762 [19.3%] vs 12 462 [26.4%]). P = .27). Among patients with diabetes, 4006 (62.7%) had adherence in the prepublication era compared with 11 245 (69.5%) in the postpublication era. P = .002), but a larger differential increase in adherence occurred over time among general surgeons relative to orthopedic surgeons . Plastic surgeons had no change in adherence over time compared with orthopedic surgeons . In addition, higher-volume surgeons had higher odds of adherence than lower-volume surgeons . For patients with diabetes, odds of adherence had a statistically significant decrease . P = .06)   compared with 12 of 19 (63.2%) in patients with diabetes. Although these findings reveal the superior effectiveness of corticosteroid injections for patients without diabetes, patients with diabetes may still gain some benefit from corticosteroid injections.34 However, more robust data are needed to fully understand the role of corticosteroid injections in patients with diabetes to establish guidelines on the optimal treatment for trigger finger in these patients. Therefore, understanding when and how patient-level factors may affect adherence will help promote high-value health care and should be considered when developing metrics to examine adherence to evidence-based care.Patient-level factors may also influence adherence to evidence-based medicine. In our study, patients with diabetes had less adherence to those without diabetes. However, we observed an overall increase in adherence for patients with diabetes over time. Diabetes may make trigger finger refractory to corticosteroid injections, and some surgeons may question the efficacy of these injections for patients with diabetes.37 Other surgeon-level factors that were not included in our model might influence adherence. We also could not investigate the physician-patient interaction, which may influence treatment decisions, or whether the treatment decisions were surgeon or patient driven. We restricted our physician cohort to those who could perform surgery, and therefore we cannot comment on the adherence of health care professionals who are not surgeons. Additionally, this study uses diagnosis codes that are for billing purposes, which may be subject to misclassification.As with other studies using administrative data, this study includes several limitations. We were unable to assess the clinical severity of the trigger finger, which may play a role in treatment decisions. Nonetheless, the research and recommendations do not account for severity of trigger finger, and surgeons should practice evidence-based medicine. We also controlled for diabetes, which, based on the literature, is the most common cause of failing conservative treatment.Our study illustrates that adherence to an evidence-based approach to the treatment of trigger finger increased over time but not specifically after the publication of important research. Surgeon variation in adherence was present with specialty and volume, accounting for a substantial amount of this variation. With national incentives to promote quality in health care, these findings suggest that implementation of evidence-based approaches for the treatment of trigger finger should be a priority.


The American Urological Association guidelines recommend 24-hour urine testing in patients with urinary stone disease to decrease the risk of stone recurrence; however, national practice patterns for 24-hour urine testing are not well characterized. Our objective is to determine the prevalence of 24-hour urine testing in patients with urinary stone disease in the Veterans Health Administration and examine patient-specific and facility-level factors associated with 24-hour urine testing. Identifying variations in clinical practice can inform future quality improvement efforts in the management of urinary stone disease in integrated healthcare systems.We accessed national Veterans Health Administration data through the Corporate Data Warehouse (CDW), hosted by the Veterans Affairs Informatics and Computing Infrastructure (VINCI), to identify patients with urinary stone disease. We defined stone formers as Veterans with one inpatient ICD-9 code for kidney or ureteral stones, two or more outpatient ICD-9 codes for kidney or ureteral stones, or one or more CPT codes for kidney or ureteral stone procedures from 2007 through 2013. We defined a 24-hour urine test as a 24-hour collection for calcium, oxalate, citrate or sulfate. We used multivariable regression to assess demographic, geographic, and selected clinical factors associated with 24-hour urine testing.We identified 130,489 Veterans with urinary stone disease; 19,288 (14.8%) underwent 24-hour urine testing. Patients who completed 24-hour urine testing were younger, had fewer comorbidities, and were more likely to be White. Utilization of 24-hour urine testing varied widely by geography and facility, the latter ranging from 1 to 40%.Fewer than one in six patients with urinary stone disease complete 24-hour urine testing in the Veterans Health Administration. In addition, utilization of 24-hour urine testing varies widely by facility identifying a target area for improvement in the care of patients with urinary stone disease. Future efforts to increase utilization of 24-hour urine testing and improve clinician awareness of targeted approaches to stone prevention may be warranted to reduce the morbidity and cost of urinary stone disease. Twenty-four-hour urine testing is employed in the metabolic evaluation and treatment of patients with urinary stone disease (USD). Clinicians use the 24-hour urine collection, along with chemical analysis of kidney stone composition, to diagnose urinary or systemic abnormalities responsible for kidney stone formation. The 24-hour urine collection can also be used to guide dietary and pharmacologic treatments for USD. Currently, the American Urological Association (AUA) guidelines recommend 24-hour urine testing for evaluating and treating recurrent stone formers and high-risk or interested first time stone formers .While there is sound physiological rationale for incorporating 24-hour urine testing in assessing USD risk, variability in the application of, and effectiveness of strategies incorporating, 24-hour urine testing are not well characterized [The Stanford Institutional Review Board and Veterans Administration Research and Development Committee (FWA00000929) approved this study and waived informed consent under the following protocol, IRB 6 Registration #4947. All records were fully anonymized before accessed. We accessed national VHA data stored in the Corporate Data Warehouse (CDW), hosted by the Veterans Affairs Informatics and Computing Infrastructure (VINCI), to identify patients with USD from 2007 through 2013. We defined “stone formers” as patients who had one or more inpatient ICD-9 codes for kidney or ureteral stones, two or more outpatient ICD-9 codes for kidney or ureteral stones, or one or more CPT codes for kidney or ureteral stone procedures in a single year [We identified the fraction of stone formers who completed a 24-hour urine collection from time of entry into the observation period through 2014. We used Logical Observation Identifiers Names and Codes (LOINC) to define a 24-hour urine collection as the presence of a 24-hour urine measurement for calcium, oxalate, citrate or sulfate. We based our definition on the assumptions that 24-hour testing for urine calcium is a sensitive proxy for USD evaluation and that 24-hour urine testing for oxalate, citrate, or sulfate is a specific proxy. We chose not to define a 24-hour urine collection as requiring the presence of all parameters that are included in a 24-hour urine stone risk panel due to our concern that it would lead to under-ascertainment of 24-hour urine testing. To ascertain if VHA includes data from 24-hour urine collections processed by an outside laboratory, we queried 24-hour urine data from our local VHA facility, which sends out 24-hour urine samples to Quest Diagnostics for measurement of urine calcium, oxalate, citrate, and sulfate, and we confirmed that these test results were recorded in the VHA.We compared demographic and clinical characteristics among stone formers who completed a 24-hour urine collection and those who did not. We examined the following factors we considered to be associated with stone risk: age, sex, race/ethnicity, history of cardiovascular disease (CVD), diabetes, cancer, hyperparathyroidism, paralysis, chronic obstructive pulmonary disease (COPD), dementia, prior 24-hour urine collection, and geographic region . To assess if a stone former received specialty stone care, we identified provider codes associated with a nephrology or urology clinic visit 6 months after their initial stone diagnosis .x2 test. We used multivariable logistic regression to estimate the odds ratios (ORs) and 95% confidence intervals (95% CI) of having a 24-hour urine collection after adjusting for age, sex, race/ethnicity, geography, prior kidney stone procedure, prior 24-hour urine collection, study entry criteria , and Charlson comorbidity index. We used the location associated with stone diagnosis code to assign each patient to one of 150 facilities across the VHA. We then compared the use of 24-hour urine testing across VHA facilities. We considered 2-tailed p-values <0.05 as statistically significant. We conducted our analysis using SAS version 9.4 .We first categorized stone formers into those who had a 24-hour urine collection and those who did not. We compared continuous variables using Student’s t-tests, and we compared categorical variables with the We identified 130,489 patients with USD from 2007 through 2013 and found that 19,288 of these patients (14.8%) completed at least one 24-hour urine collection . In bothWe assessed differences in comorbid illnesses between the two groups . Stone fUsing multivariable regression, we identified patient-specific factors associated with 24-hour urine testing in stone formers . Stone fNext we examined geographic and facility-level variation in 24-hour urine testing in stone formers across the country . RelativIn this study, we found that fewer than one in six patients with USD completed 24-hour urine testing despite guidelines recommending its use for secondary prevention. The low prevalence of 24-hour urine testing in stone formers demonstrates that clinicians are not routinely incorporating this diagnostic tool and may be falling short of adopting targeted approaches to stone prevention. We identified patient-specific and facility-level factors associated with 24-hour urine testing to determine whether one set of factors dominated. Stone formers who completed a 24-hour urine collection were more likely to do so through an outpatient encounter and were healthier, with lower rates of cardiovascular disease, dementia, and cancer, suggesting that patients who are burdened by co-morbid illness are less likely to collect a 24-hour urine sample. Stone formers were also more likely to complete a 24-hour urine test if they had more than one stone procedure or if they had completed a 24-hour urine test prior to the observation period. These findings suggest that clinicians select patients for 24-hour urine testing who have an increased risk of stone recurrence; moreover, once patients are placed on a “metabolic care pathway” guided by 24-hour urine testing, they are more likely to undergo future testing.We also found striking facility-level variation in 24-hour urine testing. Among the 150 VHA facilities delivering care to Veterans, the unadjusted proportion of stone formers receiving 24-hour urine testing ranged between 1 and 40%. This wide variation in 24-hour urine testing in stone formers across VHA facilities cannot be explained solely by differences in patient-level characteristics. For example, the average number of stone procedures performed for each stone former in the top and bottom decile of VHA facilities ordering 24-hour urine collections was nearly equal, indicating that stone formers in the top decile are not different from those in the bottom decile with respect to their need for USD procedures. Notably, even the top decile of VHA facilities ordering 24-hour urine collections do so at a rate that falls under 40% of patients with USD, highlighting a divide between recommended and real-world practice of incorporating 24-hour urine testing as a strategy for USD prevention.To date, few studies have examined the role of 24-hour urine testing in secondary prevention of USD . Milose Prior studies examining the relationship between 24-hour urine testing and specialty stone care have shown conflicting results. On the one hand, Milose et al. showed that the odds of receiving a 24-hour urine collection increases 2.9-fold when a stone former is seen by a nephrologist and increases more than 3-fold when a stone former is seen by a urologist . On the This study has several strengths. First, the VHA is a relevant population for the study of USD. Veteran patients tend to be older than civilian patients and have higher rates of co-morbid illnesses that place them at particular risk for USD . Second,ordering a 24-hour urine test. It is possible that a discrepancy between these two rates exists in the VHA and could indicate patient or facility factors that impede successful completion of 24-hour urine testing. Currently the CDW dataset does not organize order names for 24-hour urine tests in a standardized format as it does for completed 24-hour tests, which are each associated with a specific set of LOINC codes. A lack of standardization in order names for 24-hour urine tests makes it difficult to know if order names used to query the CDW dataset will encompass all order names that are used for 24-hour urine tests across the 150 VHA facilities. Future studies are thus needed to estimate the rate of 24-hour urine test ordering in the VHA (or elsewhere) and to determine if this rate differs from the rate of 24-hour urine test completion. Third, we used ICD-9 codes to identify urinary stone disease diagnoses, which opens the possibility that a diagnosis could be either over-coded  or under-coded (e.g. outpatient visit for multiple comorbid illnesses may not include a kidney stone code). Fourth, we could not specifically exclude stone formers for whom 24-hour urine testing was not indicated (e.g. un-interested first time or low risk stone formers). Fifth, it is possible that we may not have captured data from all VHA facilities that send 24-hour urine samples to an outside laboratory for processing. To address this concern, we queried 24-hour urine data from our local VHA facility, which sends out 24-hour urine samples to an outside laboratory for measurement of urine calcium, oxalate, citrate, and sulfate. We confirmed that these 24-hour urine test results were recorded in the VHA, but we acknowledge that we do not know if this would be the case for all VHA facilities. Finally, we did not capture medical care for stone formers who receive care outside the VHA.This study also has several limitations. First, our study population was comprised of Veterans, the majority of whom are men, which limits generalizability to women or persons unaffiliated with military service. Second, we defined a 24-hour urine collection to be a 24-hour urine measurement of calcium, oxalate, citrate, or sulfate, which is a subset of the measurements found in a typical 24-hour urine test. We included calcium which we believed to be a highly sensitive parameter as well as oxalate, citrate and sulfate which we believed to be a highly specific parameter to diminish false positives and negatives. We also limited our analysis to examining the rate of patients completing a 24-hour urine test rather than the rate of clinicians In conclusion, the 24-hour urine collection is acknowledged to be a valuable diagnostic tool for clinicians aiming to identify and treat metabolic risk in stone formers, yet fewer than one in six patients with USD undergo testing. This low testing frequency does not appear to be due to lack of access to specialty care because the majority of stone formers visited either a urologist or nephrologist after a stone diagnosis. Moreover, 24-hour urine testing in stone formers varied widely by geographic region and VHA facility. These regional and facility-level differences in utilization of 24-hr urine testing appear to reflect fixed practice-patterns with respect to how clinicians approach USD prevention. Future efforts to increase utilization of 24-hour urine testing and improve clinician awareness of targeted approaches to stone prevention may be warranted to reduce the morbidity and cost of USD.