Letter-only discharge process for virtual fracture clinic, a safe alternative to telephone discharge, outcomes and 12 month follow up for 1140 patients.

Telephone consult has become the accepted discharge method for virtual fracture clinic (VFC) within the United Kingdom. Telephone consultations are time consuming; many orthopaedic units lack the resources and staff to deliver large numbers of daily telephone consultations which may block the development of an effective VFC. Our study aim was to validate a letter only VFC discharge process for safety and efficacy. A letter only discharge VFC was instigated in response to the COVID-19 pandemic (April 2020). No ethical approval was required, the protocol was designed as a phased service evaluation and improvement project after change in practice. After smaller pilot audits, a comprehensive review of discharges outcomes from the VFC August-September 2021 (Phase 1) and January-March 2022 (Phase 2) was completed. Electronic letters, AE (accident and emergency) attendances and PACS database images (radiography and scans) taken over a 12 month follow up were analysed for failed discharges and adverse outcomes. Of 4810 patients reviewed in VFC, 1140 were discharged (24%). Mean patient age; 35 years (range 2-98), two thirds of patients were adults (>16 years). 116 (10%) returned with symptoms related to their initial presentation usually within the first few weeks via contact with the VFC helpline. Of the returning patients 65 were discharged again with the same advice, 48 underwent further imaging (CT/ MRI/ US scanning). 6 patients (0.5%) underwent surgery for problems relating to the initial injury; 2 knee meniscal repair/debridement, 1 ACL reconstruction, 1 fixation fifth metatarsal non-union, 2 shoulder arthroscopy. All surgeries were performed on elective timescales between 4 and 12 months after injury. Discharging letters detailed rehabilitation and symptom resolution timeframes. Our approach did not result in high return rates or adverse events (unexpected operations) in comparison to published traditional telephone discharge VFC. Units with limited staffing resources wishing to implement a VFC could safely adopt this approach as an alternative to telephone discharge.

United States blood pricing: A cross-sectional analysis of charges and reimbursement at 200 US hospitals.

A violin plot demonstrating listed chargemaster charges for RBC transfusion at 200 hospitals based on hospital ownership. A violin plot shows the volume of the samples at each point by width and lines correspond to the 25th percentile, median, and 75th percentile.

Machine Learning for Pharmacokinetic/Pharmacodynamic Modeling.

A variety of new recurrent neural networks (RNNs) including the ODE-LSTM, Phased LSTM, CTGRU and GRU-D, were evaluated on modeling irregularly sampled PK/PD data with 6 or 12 time points/day and predicting PD data of unseen dosing regimens and dosing levels. The one-compartment absorption PK model and the Indirect PK/PD model I was used to simulate the PK/PD with inter-individual variabilities in volume of distribution and residual errors in PD measurement. The four RNNs were able to successfully model daily dose (QD) PK/PD and extrapolate to twice daily (BID) dose PD based on BID PK. The RNNs not only captured the additional fluctuations in the BID regimen but also the return phase to the baseline PD. However, extrapolating to unseen dose levels outside of the dose range for training proved to be challenging for all the RNNs tested. Only the GRUD demonstrated reasonable prediction results when extrapolating to unseen doses that were 3 or 10-fold outside the training doses. Overall, these new RNNs were able to overcome some limitations of previous RNNs evaluated and showed promise of integrating neural networks in PK/PD.

Efficacy End Points and Dose Analysis of Food and Drug Administration-Approved Novel Drugs in 2020.

Background: During 2020, the Food and Drug Administration approved 53 novel drugs. Objective: Biomarkers, surrogate endpoints and dosing regimens used in early and pivotal clinical stages are evaluated. Methods: Information on various efficacy end points of 2020 Food and Drug Administration approved novel drugs was gathered from the Drug Approvals and Databases page of the Food and Drug Administration website. Endpoint data from efficacy end points for the 2019 approved novel drugs by Tong and Wang are used as a comparison. Results: Among the 53 drugs approved during 2020, 49 were for treatment of various diseases and 4 were for diagnostics. Twenty-five drug approvals (51%, relative to 49 drugs for treatment of diseases) were based on surrogate end points, consisting of 12 accelerated approvals and 13 regular approvals. There were 19 drug approvals for cancer treatments (39%, relative to 49 drugs for treatment of diseases). During 2019, there were 48 drugs approved. Forty-four were for treatment of various diseases and 4 were for diagnostics. Fourteen drug approvals (32%, relative to 44 drugs for treatment of diseases) were based on surrogate end points, consisting of 9 accelerated approvals and 5 regular approvals. There were 10 drug approvals for cancer treatments (23%, relative to 44 drugs for treatment of diseases).The approved doses were usually much closer to the highest dose tested in clinical trials (about 2-fold lower) compared with the lower dose tested in clinical trials (about 11-fold higher). Large and variable distances between the starting low dose in humans and the final approved doses indicate that finding the optimal dose in clinical trials is still a time-consuming and costly process. Further dose analysis for cancer drugs approved during 2020 showed that the distances between the starting dose in human beings and the final approved doses of cancer drugs were still large and variable, similar to distances in noncancer drugs. Stratification of drugs approved in 2020 by molecular weights shows that small molecular weights (<1000 Daltons) appeared to be smaller and less variable than those for drugs with large molecules (>1000 Daltons). (Curr Ther Res Clin Exp. 2022; 83:XXX-XXX). Conclusions: Surrogate end points with accelerated approval have been widely used for approvals, with an increasing trend from 2019 to 2020 (32% vs. 51%). The approved doses usually were much higher (10-fold) than the lowest tested dose in first-in-human trials, while much closer (2-fold lower) to the highest dose tested in clinical trials.

Noninvasive imaging of renal urea handling by CEST-MRI.

PURPOSE: Renal function is characterized by concentration of urea for removal in urine. We tested urea as a CEST-MRI contrast agent for measurement of the concentrating capacity of distinct renal anatomical regions. METHODS: The CEST contrast of urea was examined using phantoms with different concentrations and pH levels. Ten C57BL/6J mice were scanned twice at 7 T, once following intraperitoneal injection of 2M 150 µL urea and separately following an identical volume of saline. Kidneys were segmented into regions encompassing the cortex, outer medulla, and inner medulla and papilla to monitor spatially varying urea concentration. Z-spectra were acquired before and 20 minutes after injection, with dynamic scanning of urea handling performed in between via serial acquisition of CEST images acquired following saturation at +1 ppm. RESULTS: Phantom experiments revealed concentration and pH-dependent CEST contrast of urea that was both acid- and base-catalyzed. Z-spectra acquired before injection showed significantly higher CEST contrast in the inner medulla and papilla (2.3% ± 1.9%) compared with the cortex (0.15% ± 0.75%, P = .011) and outer medulla (0.12% ± 0.58%, P = .008). Urea infusion increased CEST contrast in the inner medulla and papilla by 2.1% ± 1.9% (absolute), whereas saline infusion decreased CEST contrast by -0.5% ± 2.0% (absolute, P = .028 versus urea). Dynamic scanning revealed that thermal drift and diuretic status are confounding factors. CONCLUSION: Urea CEST has a potential of monitoring renal function by capturing the spatially varying urea concentrating ability of the kidneys.

Native Plasmid-Encoded Mercury Resistance Genes Are Functional and Demonstrate Natural Transformation in Environmental Bacterial Isolates.

Plasmid-mediated horizontal gene transfer (HGT) is a major driver of genetic diversity in bacteria. We experimentally validated the function of a putative mercury resistance operon present on an abundant 8-kbp native plasmid found in groundwater samples without detectable levels of mercury. Phylogenetic analyses of the plasmid-encoded mercury reductases from the studied groundwater site show them to be distinct from those reported in proximal metal-contaminated sites. We synthesized the entire native plasmid and demonstrated that the plasmid was sufficient to confer functional mercury resistance in Escherichia coli Given the possibility that natural transformation is a prevalent HGT mechanism in the low-cell-density environments of groundwaters, we also assayed bacterial strains from this environment for competence. We used the native plasmid-encoded metal resistance to design a screen and identified 17 strains positive for natural transformation. We selected 2 of the positive strains along with a model bacterium to fully confirm HGT via natural transformation. From an ecological perspective, the role of the native plasmid population in providing advantageous traits combined with the microbiome's capacity to take up environmental DNA enables rapid adaptation to environmental stresses.IMPORTANCE Horizontal transfer of mobile genetic elements via natural transformation has been poorly understood in environmental microbes. Here, we confirm the functionality of a native plasmid-encoded mercury resistance operon in a model microbe and then query for the dissemination of this resistance trait via natural transformation into environmental bacterial isolates. We identified 17 strains including Gram-positive and Gram-negative bacteria to be naturally competent. These strains were able to successfully take up the plasmid DNA and obtain a clear growth advantage in the presence of mercury. Our study provides important insights into gene dissemination via natural transformation enabling rapid adaptation to dynamic stresses in groundwater environments.

Metaplastic breast carcinoma: a case report and systematic review of the literature.

A 78-year-old retired woman was diagnosed with metaplastic breast carcinoma (MBC), a rare tumor, in our hospital. We reviewed 15 articles with a total of 1328 patients to determine the epidemiology, clinical features, biomarkers, histology, management and outcome of patients with this tumor. The mean age at presentation is 58.5 years (range 32-83). Eighty-one percent of patients presented either with a breast mass or abnormal mammographic finding. Twenty-three percent of patients had a family history of breast cancer. Estrogen receptors were only found in 12%, progesterone receptors in 10% and HER2 in 6% of patients. The main method of treatment was mastectomy (66.9%) in combination with chemotherapy (57%) and radiotherapy (47%). Five-year disease-free survival ranged between 40% and 84% and 5-year overall survival ranged between 64 and 83%. We have further reviewed the nature of this disease in the light of advancement in genetics, such as microarray gene expression profiling. The relationship of MBC with triple-negative tumor and basal-like tumor is discussed. It is hoped that advances in genetics and biomarkers will bring forward the era of personalized medicine in the treatment of breast carcinoma.

Giant cystic lymphangioma of the liver.

BACKGROUND: Giant cystic lymphangiomas of the liver are rare malformations of the lymphatic system usually found in children. CASE PRESENTATION: A 35-year-old man presenting with right upper quadrant abdominal pain for 7 months visited our clinic. Ultrasound, CT, and MRI examination demonstrated a giant cystic mass in the right trisegment of the liver. The patient underwent surgical resection and histological results of the resected specimen confirmed the diagnosis of giant cystic lymphangioma. The right upper quadrant abdominal pain subsided after the surgical resection and the patient recovered well. CONCLUSION: Surgical resection is an effective therapy in treating giant cystic lymphangioma.