Cutaneous Metastases in Progressive Prostate Adenocarcinoma: A Case Report and Literature Review.

Prostate cancer has an indolent progression course and commonly metastasizes to the vertebrae bone and regional lymph nodes. We report a patient with prostate cancer who has developed cutaneous metastases in multiple regions, including the right infraclavicular and abdominal area, as well as the left supraclavicular region. It presented as isolated, prominent nodules that were microscopically proven to be of prostate adenocarcinoma when biopsied. This rare presentation is a marker of an advanced disease course with a poor prognosis in castrate-resistant prostate cancer. Thorough clinical examination to rule out metastasis from the prostate and other dermatological conditions is paramount as well as ensuring early detection and optimizing patient outcomes.

Uncontrolled Arterial Bleeding in a Patient With Massive Right Calf Hematoma: A Case Report and a Review of the Literature.

A hematoma is a collection of pooled blood that can be confined to a space under the skin, tissue, or organ. It occurs due to injury to the vasculature arising from trauma, previous surgeries, or vascular defects. Anticoagulants can remarkably increase a patient's risk for hematoma formation. Most hematomas will resolve spontaneously over time, but there are certain instances where surgical intervention becomes necessary. We present a case of a 71-year-old female on anticoagulants who presented to the emergency department (ED) with an expanding hematoma on her right leg after a fall and had to undergo an emergency surgical evacuation. The etiology, appropriate management, and complications of hematomas will also be covered in this paper.

Peripheral Administration of Selective Glycine Transporter-2 Inhibitor, Oleoyl-D-Lysine, Reverses Chronic Neuropathic Pain but Not Acute or Inflammatory Pain in Male Mice.

Aberrations in spinal glycinergic signaling are a feature of pain chronification. Normalizing these changes by inhibiting glycine transporter (GlyT)-2 is a promising treatment strategy. However, existing GlyT2 inhibitors (e.g., ORG25543) are limited by narrow therapeutic windows and severe dose-limiting side effects, such as convulsions, and are therefore poor candidates for clinical development. Here, intraperitoneally administered oleoyl-D-lysine, a lipid-based GlyT2 inhibitor, was characterized in mouse models of acute (hot plate), inflammatory (complete Freund's adjuvant), and chronic neuropathic (chronic constriction injury) pain. Side effects were also assessed on a numerical rating score, convulsions score, for motor incoordination (rotarod), and for respiratory depression (whole body plethysmography). Oleoyl-D-lysine produced near complete antiallodynia for chronic neuropathic pain, but no antiallodynia/analgesia in inflammatory or acute pain. No side effects were seen at the peak analgesic dose, 30 mg/kg. Mild side effects were observed at the highest dose, 100 mg/kg, on the numerical rating score, but no convulsions. These results contrasted markedly with ORG25543, which reached less than 50% reduction in allodynia score only at the lethal/near-lethal dose of 50 mg/kg. At this dose, ORG25543 caused maximal side effects on the numerical rating score and severe convulsions. Oleoyl-D-lysine (30 mg/kg) did not cause any respiratory depression, a problematic side effect of opiates. These results show the safe and effective reversal of neuropathic pain in mice by oleoyl-D-lysine and provide evidence for a distinct role of glycine in chronic pain over acute or short-term pain conditions. SIGNIFICANCE STATEMENT: Partially inhibiting glycine transporter (GlyT)-2 can alleviate chronic pain by restoring lost glycinergic function. Novel lipid-based GlyT2 inhibitor ol-D-lys is safe and effective in alleviating neuropathic pain, but not inflammatory or acute pain. Clinical application of GlyT2 inhibitors may be better suited to chronic neuropathic pain over other pain aetiologies.

Thoracic endovascular repair of chronic type B aortic dissection: a systematic review.

BACKGROUND: At present, the optimal management strategy for chronic type B aortic dissection (CTBAD) remains unknown, as equipoise remains regarding medical management versus endovascular treatment versus open surgery. However, the results over recent years of thoracic endovascular aortic repair (TEVAR) in CTBAD appear promising. The aim of this systematic review was to provide a comprehensive analysis of the available data reporting outcomes and survival rates for TEVAR in CTBAD. METHODS: Electronic searches of six databases were performed from inception to April 2021. All studies reporting outcomes, specifically 30-day mortality rates, for endovascular repair of CTBAD were identified. Relevant data were extracted, and a random-effects meta-analysis of proportions or means was performed to aggregate the data. Survival data were pooled using data derived from original Kaplan-Meier curves, which allows reconstruction of individual patient data. RESULTS: Forty-eight studies with 2,641 patients were identified. Early (<30 days) all-cause and aortic-related mortality rates were low at 1.6% and 0.5%, respectively. Incidence of retrograde type A dissection in the post-operative period was only 1.4%. There were also low rates of cerebrovascular accidents and spinal cord injury (1.1% and 0.9%, respectively). Late follow-up all-cause mortality was 8.0%, however, late aortic-related mortality was only 2.4%. Reintervention rates were 10.1% for endovascular and 6.7% for surgical reintervention. Pooled rates of overall survival at 1-, 3-, 5- and 10-year were 91.5%, 84.7%, 77.7% and 56.3%, respectively. CONCLUSIONS: The significant heterogeneity in the available evidence and absence of consensus reporting standards are important considerations and concern when interpreting the data. Evaluation of the evidence suggests that TEVAR for CTBAD is a safe procedure with low rates of complications. However, the optimal treatment strategy for CTBAD remains debatable and requires further research. Evidence from high-quality registries and clinical trials are required to address these challenges.

Gridded daily weather data for North America with comprehensive uncertainty quantification.

Access to daily high-resolution gridded surface weather data based on direct observations and over long time periods is essential for many studies and applications including vegetation, wildlife, soil health, hydrological modelling, and as driver data in Earth system models. We present Daymet V4, a 40-year daily meteorological dataset on a 1 km grid for North America, Hawaii, and Puerto Rico, providing temperature, precipitation, shortwave radiation, vapor pressure, snow water equivalent, and day length. The dataset includes an objective quantification of uncertainty based on strict cross-validation analysis for temperature and precipitation results. The dataset represents several improvements from a previous version, and this data descriptor provides complete documentation for updated methods. Improvements include: reductions in the timing bias of input reporting weather station measurements; improvement to the three-dimensional regression model techniques in the core algorithm; and a novel approach to handling high elevation temperature measurement biases. We show cross-validation analyses with the underlying weather station data to demonstrate the technical validity of new dataset generation methods, and to quantify improved accuracy.

Revisiting Health Rights Litigation and Access to Medications in Costa Rica: Preliminary Evidence from the Cochrane Collaboration Reform.

In response to the incremental creation of an expansive constitutional right to health in Costa Rica, the country's rights-friendly constitutional chamber of the Supreme Court (known as the Sala IV) unleashed a flood of litigation for medications, treatments, and other health care issues. This development was met by widespread criticism from within the health sector, which complained that the court's jurisprudence routinely elevated the right to health above financial considerations, thus posing a threat to the financial well-being of the state-run health care system.1 Further, a 2014 study by Ole Frithjof Norheim and Bruce Wilson examining successful health rights litigation revealed that more than 70% of favorable rulings were for low-priority medications, suggesting a lack of fairness in access to medications in Costa Rica.2 To address some of these criticisms, the Sala IV initiated a partnership in 2014 with the Cochrane Collaboration to incorporate medical expert evaluations into its decision-making process for claims seeking access to medications. This article examines the court's reformed decision-making process to determine whether the increased reliance on medical expertise has changed health rights jurisprudence. We reviewed all medication claims from 2016 and classified the successful cases into four groups using standard priority-setting criteria. We then compared these results with rulings issued in 2008, prior to the court's reform (and the year analyzed in Norheim and Wilson's study). Our analysis reveals that under the court's new rules, the probability of winning a medication lawsuit has increased significantly; moreover, the percentage of rulings granting experimental medications has declined while the percentage granting high-priority medications has increased. Based on these results, in comparison to the court's pre-reform jurisprudence, we can tentatively conclude that the new process has led to some minor gains in fairness.

Ageing and Learning in Australia: Arguing an Evidence Base for Informed and Equitable Policy.

BACKGROUND: Given Australia's population ageing and predicted impacts related to health, productivity, equity and enhancing quality of life outcomes for senior Australians, lifelong learning has been identified as a pathway for addressing the risks associated with an ageing population. To date Australian governments have paid little attention to addressing these needs and thus, there is an urgent need for policy development for lifelong learning as a national priority. The purpose of this article is to explore the current lifelong learning context in Australia and to propose a set of factors that are most likely to impact learning in later years. CONCLUSION: Evidence based policy that understands and incorporates learning opportunities for all citizens is required to meet emerging global challenges. Providing appropriate learning opportunities to seniors is one clear pathway for achieving diverse health, social and economic outcomes.

Lilac and honeysuckle phenology data 1956-2014.

The dataset is comprised of leafing and flowering data collected across the continental United States from 1956 to 2014 for purple common lilac (Syringa vulgaris), a cloned lilac cultivar (S. x chinensis 'Red Rothomagensis') and two cloned honeysuckle cultivars (Lonicera tatarica 'Arnold Red' and L. korolkowii 'Zabeli'). Applications of this observational dataset range from detecting regional weather patterns to understanding the impacts of global climate change on the onset of spring at the national scale. While minor changes in methods have occurred over time, and some documentation is lacking, outlier analyses identified fewer than 3% of records as unusually early or late. Lilac and honeysuckle phenology data have proven robust in both model development and climatic research.

Establishing and maintaining social connectivity: An understanding of the lived experiences of older adults residing in regional and rural communities.

OBJECTIVE: To better understand how to plan for an ageing demographic that resides in ever-changing community typologies. DESIGN: Semi-structured in-depth interviews. SETTING: Community settings in rural and regional towns in Queensland. PARTICIPANTS: Twenty-two people aged over 65 years living in regional and rural Australia. INTERVENTIONS: Qualitative study of social connectedness. MAIN OUTCOME MEASURE(S): Thematic qualitative analysis. RESULTS: Formal and informal social contact, through family, friends and social groups, was found to be important to the everyday lives of the participants. CONCLUSIONS: Social connections for older adults are important in maintaining independence and community engagement.

Health rights litigation and access to medicines: priority classification of successful cases from Costa Rica's constitutional chamber of the Supreme Court.

Although Costa Rica has no explicit constitutional right to health, its constitutional chamber of the Supreme Court (Sala IV) has become increasingly central to the resolution of many health care decisions. Some argue that courts' decisions about individuals' access to very expensive medications could upset the country's medical priorities and harm the state's general health care provision capacity. This article assesses whether health rights litigation concerning the right to medications leads to more fairness in access to medications in Costa Rica. We review randomly selected access to medicines cases successfully claimed at the Sala IV in 2008 and classify them into four priority groups using standard priority-setting criteria. We find that 2.7% of the successful cases fall into priority group I (highest priority), 27% in group II, 48.6% in group III, and 21.6% in group IV (experimental treatment). Our analysis reveals a majority of successful health rights litigation for medications results in court-mandated provision of new, expensive drugs, many with only marginal benefits. More than 70% of the successful cases evaluated concerned medications judged to be of low priority. Based on these cases, we cannot conclude that litigation leads to more fairness in access to medications.

Postdischarge pharmacist medication reconciliation: impact on readmission rates and financial savings.

OBJECTIVE: To assess the impact of ambulatory clinical pharmacist medication therapy assessment and reconciliation for patients postdischarge in terms of hospital readmission rates, financial savings, and medication discrepancies. SETTING: Group Health Cooperative (Group Health) in Washington State, from September 2009 through February 2010. PRACTICE DESCRIPTION: Group Health is a nonprofit integrated group practice and health plan, operating 25 primary care medical centers and 5 specialty centers. Group Health's practice design is a patient-centered medical home model. PRACTICE INNOVATION: All patients identified as high risk for readmission were followed by Group Health care management. Patients in care management who received a phone call from a pharmacist 3 to 7 days postdischarge for medication therapy assessment and reconciliation were identified as the medication review group (n = 243). Patients who did not receive clinical pharmacist intervention were included in the comparison group (n = 251). MAIN OUTCOME MEASURES: Readmission rates, financial savings, and medication discrepancies. RESULTS: Patients who received medication therapy assessment and reconciliation had decreased readmission rates at 7, 14, and 30 days postdischarge, with statistical significance at 7 and 14 days. Medication review versus comparison readmission rates were as follows: 7 days: 0.8% vs. 4% ( P = 0.01); 14 days: 5% vs. 9% ( P = 0.04); and 30 days: 12% vs. 14% ( P = 0.29). Financial savings for Group Health per 100 patients who received medication reconciliation was an estimated $35,000, translating to more than $1,500,000 in savings annually. Of patients, 80% had at least one medication discrepancy upon discharge. CONCLUSION: Most literature on medication reconciliation evaluates inpatient processes, whereas data on medication reconciliation postdischarge are limited. Our data support the hypothesis that medication assessment and reconciliation by pharmacists 3 to 7 days postdischarge can decrease readmissions and provide cost savings.

Metaphysics and medical education: taking holism seriously.

Medical education is now suffused with concepts that have their source outside the traditional scientific and medical disciplines: concepts such as holism, connectedness and reflective practice. Teaching of these, and other problematic concepts such as medical uncertainty and error, has been defined more by the challenge they pose to the standard model rather than being informed by a strong positive understanding. This challenge typically involves a critical engagement with the idea of objectivity, which is rarely acknowledged as an inherently metaphysical critique. Consequently, these ideas prove to be difficult to teach well. I suggest that the lack of an integrating, positive narrative is the reason for teaching difficulty, and propose that what is needed is an explicit commitment to teach the metaphysics of medicine, with the concept of holism being the fulcrum on which the remaining concepts turn. An acknowledged metaphysical narrative will encompass the scientific realism that medical students typically bring to their tertiary education, and at the same time enable a bigger picture to be drawn that puts the newer and more problematic concepts into context.

A Paddock to reef monitoring and modelling framework for the Great Barrier Reef: Paddock and catchment component.

Targets for improvements in water quality entering the Great Barrier Reef (GBR) have been set through the Reef Water Quality Protection Plan (Reef Plan). To measure and report on progress towards the targets set a program has been established that combines monitoring and modelling at paddock through to catchment and reef scales; the Paddock to Reef Integrated Monitoring, Modelling and Reporting Program (Paddock to Reef Program). This program aims to provide evidence of links between land management activities, water quality and reef health. Five lines of evidence are used: the effectiveness of management practices to improve water quality; the prevalence of management practice adoption and change in catchment indicators; long-term monitoring of catchment water quality; paddock & catchment modelling to provide a relative assessment of progress towards meeting targets; and finally marine monitoring of GBR water quality and reef ecosystem health. This paper outlines the first four lines of evidence.

Using principal component analysis to aid bayesian network development for prediction of critical care patient outcomes.

BACKGROUND: Predicting an intensive care unit patient's outcome is highly desirable. An end goal is for computational techniques to provide updated, accurate predictions about changing patient condition using a manageable number of physiologic parameters. METHODS: Principal component analysis was used to select input parameters for critical care patient outcome models. Vital signs and laboratory values from each patient's hospital stay along with outcomes ("Discharged" vs. "Deceased") were collected retrospectively at a Level I Trauma-Military Medical Center in the southwest; intensive care unit patients were included if they had been admitted for burn, infection, or hypovolemia during a 5-year period ending October 2007. Principal component analysis was used to determine which of the 24 parameters would serve as inputs in a bayesian network developed for outcome prediction. RESULTS: Data for 581 patients were collected. Pulse pressure, heart rate, temperature, respiratory rate, sodium, and chloride were found to have statistically significant differences between Discharged and Deceased groups for "Hypovolemia" patients. For "Burn" patients, pulse pressure, hemoglobin, hematocrit, and potassium were found to have statistically significant differences. For a "Combined" group, heart rate, temperature, respiratory rate, sodium, and chloride had statistically significant differences. A bayesian network based on these results, developed for the Combined group, achieved an accuracy of 75% when predicting patient outcome. CONCLUSIONS: Outcome prediction for critical care patients is possible. Future work should explore model development using additional temporal data and should include prospective validation. Such technology could serve as the basis of real-time intelligent monitoring systems for critical patients.

Fuel consumption estimation for kerbside municipal solid waste (MSW) collection activities.

Fuel consumption during seven different daily activities of a garbage co-collection truck and a normal packer truck was estimated from the trucks' global positioning system (GPS) data and fuel consumption records. The co-collection and the normal garbage packer consumed approximately 1.8 L and 1.26 L of diesel per km, respectively, while travelling within the collection areas. Using these fuel rates and the GPS data, the results show that both types of trucks consumed more than 60% of daily total fuel while actually collecting waste on the route. The average daily fuel consumption was 2-4 times higher on rural routes compared to urban areas. Fuel consumption varied significantly depending on the housing density along the collection route. In addition, approximately 5-6 times as much fuel was required to collect a kilogram of waste on a rural route compared to an urban route. Potential methods of reducing fuel consumption were examined. Consistent use of optimal collection routes could potentially save an average of 7.5 L of fuel per truck per day. Reducing the loading time per stop was also studied, but the results suggest that this method does not have significant potential to reduce fuel consumption.

Assessment of shellfish practices in licensed retail food establishments in response to increased Vibrio illnesses in a landlocked area.

Cases of non-cholera Vibrio illness are typically associated with exposure to shellfish from marine coastal areas (U.S. Food and Drug Administration, Center for Food Safety and Applied Nutrition, 2009), not landlocked states such as Colorado. In 2004, a 2.8-fold increase in the incidence of non-cholera Vibrio cases in the Tri-County Health Department (TCHD) jurisdiction of Colorado prompted scrutiny of shellfish practices in local retail food establishments. Forty-three percent of establishments serving raw shellfish in the TCHD jurisdiction were in violation of one or more sections of the Colorado Retail Food Establishment Rules and Regulations (Colorado Department of Public Health and Environment, 2007a). The frequency of violations and the underutilization of safer, post-harvest processed shellfish may result in significant hazards to consumers if these practices continue.

Using Bayesian networks and rule-based trending to predict patient status in the intensive care unit.

Multivariate Bayesian models trained with machine learning, in conjunction with rule-based time-series statistical techniques, are explored for the purpose of improving patient monitoring. Three vital sign data streams and known outcomes for 36 intensive care unit (ICU) patients were captured retrospectively and used to train a set of Bayesian net models and to construct time-series models. Models were validated on a reserved dataset from 16 additional patients. Receiver operating characteristic (ROC) curves were calculated. Area under the curve (AUC) was 91% for predicting improving outcome. The model's AUC for predicting declining outcome increased from 70% to 85% when the model was indexed to personalized baselines for each patient. The rule-based trending and alerting system was accurate 100% of the time in alerting a subsequent decline in condition. These techniques promise to improve the monitoring of ICU patients with high-sensitivity alerts, fewer false alarms, and earlier intervention.