All Publications

  • Does Societal Cost Information Affect Patient Decision-Making in Carpal Tunnel Syndrome? A Randomized Controlled Trial. Hand (New York, N.Y.) Kortlever, J. T., Zhuang, T., Ring, D., Reichel, L. M., Vagner, G. A., Kamal, R. N. 2019: 1558944719873399


    Background: Despite studies demonstrating the effects of out-of-pocket costs on decision-making, the effect of societal cost information on patient decision-making is unknown. Given the considerable societal impact of cost of care for carpal tunnel syndrome (CTS), providing societal cost data to patients with CTS could affect decision-making and provide a strategy for reducing national health care costs. Therefore, we assessed the following hypotheses: (1) there is no difference in treatment choice (surgery vs no surgery) in a hypothetical case of mild CTS between patients randomized to receive societal cost information compared with those who did not receive this information; (2) there are no factors (eg, sex, experience with a previous diagnosis of CTS, or receiving societal cost information) independently associated with the choice for surgery; and (3) there is no difference in attitudes toward health care costs between patients choosing surgery and those who did not. Methods: In this randomized controlled trial using a hypothetical scenario, we prospectively enrolled 184 new and return patients with a nontraumatic upper extremity diagnosis. We recorded patient demographics, treatment choice in the hypothetical case of mild CTS, and their attitudes toward health care costs. Results: Treatment choice was not affected by receiving societal cost information. None of the demographic or illness factors assessed were independently associated with the choice for surgery. Patients declining surgery felt more strongly that doctors should consider their out-of-pocket costs when making recommendations. Conclusions: Providing societal cost information does not seem to affect decision-making and may not reduce the overall health care costs. For patients with CTS, health policy could nudge toward better resource utilization and finding the best care pathways for nonoperative and invasive treatments.

    View details for DOI 10.1177/1558944719873399

    View details for PubMedID 31517517

  • The Use of Preoperative Antibiotics in Elective Soft-Tissue Procedures in the Hand: A Critical Analysis Review. JBJS reviews Shapiro, L. M., Zhuang, T., Li, K., Kamal, R. N. 2019

    View details for DOI 10.2106/JBJS.RVW.18.00168

    View details for PubMedID 31436581

  • Financial Distress Is Associated With Delay in Seeking Care for Hand Conditions. Hand (New York, N.Y.) Zhuang, T., Eppler, S. L., Shapiro, L. M., Roe, A. K., Yao, J., Kamal, R. N. 2019: 1558944719866889


    Background: As medical costs continue to rise, financial distress due to these costs has led to poorer health outcomes and patient cost-coping behavior. Here, we test the null hypothesis that financial distress is not associated with delay of seeking care for hand conditions. Methods: Eighty-seven new patients presenting to the hand clinic for nontraumatic conditions completed our study. Patients completed validated instruments for measuring financial distress, pain catastrophizing, and pain. Questions regarding delay of care were included. The primary outcome was self-reported delay of the current hand clinic visit. Results: Patients who experience high financial distress differed significantly from those who experience low financial distress with respect to age, race, annual household income, and employment status. Those experiencing high financial distress were more likely to report having delayed their visit to the hand clinic (57% vs 30%), higher pain catastrophizing scores (17.7 vs 7.6), and higher average pain in the preceding week (4.5 vs 2.3). After adjusting for age, sex, and pain, high financial distress (adjusted odds ratio [OR] = 4.90) and pain catastrophizing score (adjusted OR = 0.96) were found to be independent predictors of delay. Financial distress was highly associated with annual household income in a multivariable linear regression model. Conclusions: Patients with nontraumatic hand conditions who experience higher financial distress are more likely to delay their visit to the hand clinic. Within health care systems, identification of patients with high financial distress and targeted interventions (eg, social or financial services) may help prevent unnecessary delays in care.

    View details for DOI 10.1177/1558944719866889

    View details for PubMedID 31409138

  • Arthrodesis of the Foot or Ankle in Adult Patients with Congenital Clubfoot. Cureus Zhuang, T., El-Banna, G., Frick, S. 2019; 11 (12): e6505


    Background Although clubfoot that was corrected in childhood rarely recurs in adulthood, persistent deformities or arthritic pain may require further treatment during adulthood. Little evidence exists on the operative procedures utilized in adult clubfoot patients, who were previously treated for congenital clubfoot in childhood, for residual or recurrent deformity or pain. Objective The objective of this study is to characterize the types and frequencies of procedures utilized in adult clubfoot patients, who were previously treated for congenital clubfoot in childhood. Methods A two-pronged approach was employed to describe the operative procedures used in adult clubfoot patients. First, a literature review of all reported cases of operative treatment in adult clubfoot patients who were previously treated in childhood was performed. Second, an analysis of the operative treatments used in adult patients with a diagnosis of congenital clubfoot was conducted using a large, administrative claims database. Results In the literature review, arthrodesis was the most cited operative treatment and reported in four out of the eight studies included. Osteotomies were also reported in the literature. In the database analysis, 94 hindfoot arthrodesis procedures were identified in 73 patients, out of 1,198 adult patients in the database with a diagnosis of congenital clubfoot. Sixty-two patients out of 1,198 adult clubfoot patients received osteotomies. An insufficient number of total ankle arthroplasties were reported for further analysis. Conclusions Operative treatment in adult clubfoot patients who were treated for congenital clubfoot in childhood includes hindfoot arthrodesis and osteotomy procedures. Total ankle arthroplasty has not been reported in the literature for these patients.

    View details for DOI 10.7759/cureus.6505

    View details for PubMedID 32025426

    View details for PubMedCentralID PMC6988724

  • Variations in Utilization of Carpal Tunnel Release Among Medicaid Beneficiaries. The Journal of hand surgery Zhuang, T., Eppler, S. L., Kamal, R. N. 2018


    PURPOSE: To evaluate the null hypothesis that Medicaid patients receive carpal tunnel release (CTR) at the same time interval from diagnosis as do patients with Medicare Advantage or private insurance.METHODS: We conducted a retrospective review using a database containing claims records from 2007 to 2016. The cohort consisted of patient records with a diagnosis code of carpal tunnel syndrome (CTS) and a procedural code for CTR within 3 years of diagnosis. We stratified patients into 3 groups by insurance type (Medicaid managed care, Medicare Advantage, and private) for an analysis of the time from diagnosis until surgery and use of preoperative electrodiagnostic testing.RESULTS: Of all patients who received CTR within 3 years of diagnosis, Medicaid patients experienced longer intervals from CTS diagnosis to CTR compared with Medicare Advantage and privately insured patients (median, 99 days vs 65 and 62 days, respectively). The Medicaid cohort was significantly less likely to receive CTR within 1 year of diagnosis compared with the Medicare Advantage cohort (adjusted odds ratio [OR]= 0.54) or within 6 months of diagnosis compared with the privately insured cohort (adjusted OR= 0.61). Those in the Medicaid cohort were less likely to receive electromyography and nerve conduction studies within 9 months before surgery compared with their Medicare Advantage (adjusted OR= 0.43) and privately insured (adjusted OR= 0.41) counterparts. These effects were statistically significant after accounting for age, sex, region, and Charlson comorbidity index.CONCLUSIONS: Medicaid managed care patients experience longer times from diagnosis to surgery compared with Medicare Advantage or privately insured patients in this large administrative claims database. Similar variation exists in the use of electrodiagnostic testing based on insurance type.CLINICAL RELEVANCE: Medicaid patients may experience barriers to CTS care, such as delays from diagnosis to surgery and reduced use of electrodiagnostic testing.

    View details for PubMedID 30579689

  • Mechanism of Hydrocarbon Functionalization by an Iodate/Chloride System: The Role of Ester Protection ACS CATALYSIS Schwartz, N. A., Boaz, N. C., Kalman, S. E., Zhuang, T., Goldberg, J. M., Fu, R., Nielsen, R. J., Goddard, W. A., Groves, J. T., Gunnoe, T. 2018; 8 (4): 3138–49
  • Alkyl Isocyanates via Manganese-Catalyzed C-H Activation for the Preparation of Substituted Ureas JOURNAL OF THE AMERICAN CHEMICAL SOCIETY Huang, X., Zhuang, T., Kates, P. A., Gao, H., Chen, X., Groves, J. T. 2017; 139 (43): 15407–13


    Organic isocyanates are versatile intermediates that provide access to a wide range of functionalities. In this work, we have developed the first synthetic method for preparing aliphatic isocyanates via direct C-H activation. This method proceeds efficiently at room temperature and can be applied to functionalize secondary, tertiary, and benzylic C-H bonds with good yields and functional group compatibility. Moreover, the isocyanate products can be readily converted to substituted ureas without isolation, demonstrating the synthetic potential of the method. To study the reaction mechanism, we have synthesized and characterized a rare MnIV-NCO intermediate and demonstrated its ability to transfer the isocyanate moiety to alkyl radicals. Using EPR spectroscopy, we have directly observed a MnIV intermediate under catalytic conditions. Isocyanation of celestolide with a chiral manganese salen catalyst followed by trapping with aniline afforded the urea product in 51% enantiomeric excess. This represents the only example of an asymmetric synthesis of an organic urea via C-H activation. When combined with our DFT calculations, these results clearly demonstrate that the C-NCO bond was formed through capture of a substrate radical by a MnIV-NCO intermediate.

    View details for DOI 10.1021/jacs.7b07658

    View details for Web of Science ID 000414506400023

    View details for PubMedID 28976738

  • Involvement of nitric oxide synthase in matrix metalloproteinase-9-and/or urokinase plasminogen activator receptor-mediated glioma cell migration BMC CANCER Zhuang, T., Chelluboina, B., Ponnala, S., Velpula, K., Rehman, A. A., Chetty, C., Zakharian, E., Rao, J. S., Veeravalli, K. 2013; 13: 590


    Src tyrosine kinase activates inducible nitric oxide synthase (iNOS) and, in turn, nitric oxide production as a means to transduce cell migration. Src tyrosine kinase plays a key proximal role to control α9β1 signaling. Our recent studies have clearly demonstrated the role of α9β1 integrin in matrix metalloproteinase-9 (MMP-9) and/or urokinase plasminogen activator receptor (uPAR)-mediated glioma cell migration. In the present study, we evaluated the involvement of α9β1 integrin-iNOS pathway in MMP-9- and/or uPAR-mediated glioma cell migration.MMP-9 and uPAR shRNAs and overexpressing plasmids were used to downregulate and upregulate these molecules, respectively in U251 glioma cells and 5310 glioma xenograft cells. The effect of treatments on migration and invasion potential of these glioma cells were assessed by spheroid migration, wound healing, and Matrigel invasion assays. In order to attain the other objectives we also performed immunocytochemical, immunohistochemical, RT-PCR, Western blot and fluorescence-activated cell sorting (FACS) analysis.Immunohistochemical analysis revealed the prominent association of iNOS with glioblastoma multiforme (GBM). Immunofluorescence analysis showed prominent expression of iNOS in glioma cells. MMP-9 and/or uPAR knockdown by respective shRNAs reduced iNOS expression in these glioma cells. RT-PCR analysis revealed elevated iNOS mRNA expression in either MMP-9 or uPAR overexpressed glioma cells. The migration potential of MMP-9- and/or uPAR-overexpressed U251 glioma cells was significantly inhibited after treatment with L-NAME, an inhibitor of iNOS. Similarly, a significant inhibition of the invasion potential of the control or MMP-9/uPAR-overexpressed glioma cells was noticed after L-NAME treatment. A prominent reduction of iNOS expression was observed in the tumor regions of nude mice brains, which were injected with 5310 glioma cells, after MMP-9 and/or uPAR knockdown. Protein expressions of cSrc, phosphoSrc and p130Cas were reduced with simultaneous knockdown of both MMP-9 and uPAR.Taken together, our results from the present and earlier studies clearly demonstrate that α9β1 integrin-mediated cell migration utilizes the iNOS pathway, and inhibition of the migratory potential of glioma cells by simultaneous knockdown of MMP-9 and uPAR could be attributed to the reduced α9β1 integrin and iNOS levels.

    View details for DOI 10.1186/1471-2407-13-590

    View details for Web of Science ID 000329345100001

    View details for PubMedID 24325546

    View details for PubMedCentralID PMC3878845