Physiologically based pharmacokinetic modeling (PBPK) to predict drug-drug interactions for encorafenib. Part II. Prospective predictions in hepatic and renal impaired populations with clinical inhibitors and inducers

Encorafenib, a potent BRAF kinase inhibitor gets significantly metabolised by CYP3A4 (83%) and CYP2C19 (16%) and is a substrate for P-glycoprotein (P-gp). Due to significant metabolism by CYP3A4, encorafenib exposure can increase in hepatic and renal impairment and may lead to altered magnitude of drug-drug interactions (DDI). Hence, it is necessary to assess the exposures & DDI's in impaired population.Physiologically based pharmacokinetic modelling (PBPK) was utilised to determine the exposures of encorafenib in hepatic and renal impairment along with altered DDI's. Prospective DDI's were predicted with USFDA recommended clinical CYP3A4, CYP2C19, P-gp inhibitors and CYP3A4 inducers.PBPK models for encorafenib, perpetrators simulated PK parameters within 2-folds error. Encorafenib exposures significantly increased in hepatic as compared to renal impairment because of reduced CYP3A4 levels.Hepatic impairment caused changes in inhibition and induction DDI's, when compared to healthy population. Renal impairment did not cause significant changes in DDIs except for itraconazole. P-gp, CYP2C19 inhibitors did not result in altered DDI's. The DDI's were found to have insignificant correlation with relative exposure increase of perpetrators in case of impairment. Overall, this work signifies use of PBPK modelling for DDI's evaluations in hepatic and renal impairment populations.

Physiologically based pharmacokinetic modelling to predict drug-drug interactions for encorafenib. Part I. Model building, validation, and prospective predictions with enzyme inhibitors, inducers, and transporter inhibitors

Encorafenib, a potent BRAF kinase inhibitor undergoes significant metabolism by CYP3A4 (83%) and CYP2C19 (16%) and also a substrate of P-glycoprotein (P-gp). Because of this, encorafenib possesses potential for enzyme-transporter related interactions. Clinically, its drug-drug interactions (DDIs) with CYP3A4 inhibitors (posaconazole, diltiazem) were reported and hence there is a necessity to study DDIs with multiple enzyme inhibitors, inducers, and P-gp inhibitors.USFDA recommended clinical CYP3A4, CYP2C19, P-gp inhibitors, CYP3A4 inducers were selected and prospective DDIs were simulated using physiologically based pharmacokinetic modelling (PBPK). Impact of dose (50 mg vs. 300 mg) and staggering of administrations (0-10 h) on the DDIs were predicted.PBPK models for encorafenib, perpetrators simulated PK parameters within twofold prediction error. Clinically reported DDIs with posaconazole and diltiazem were successfully predicted.CYP2C19 inhibitors did not result in significant DDI whereas strong CYP3A4 inhibitors resulted in DDI ratio up to 4.5. Combining CYP3A4, CYP2C19 inhibitors yielded DDI equivalent CYP3A4 alone. Strong CYP3A4 inducers yielded DDI ratio up to 0.3 and no impact of P-gp inhibitors on DDIs was observed. The DDIs were not impacted by dose and staggering of administration. Overall, this work indicated significance of PBPK modelling for evaluating clinical DDIs with enzymes, transporters and interplay.

Pattern of sudden cardiac deaths

BACKGROUND AND OBJECTIVE

Sudden cardiac death can be defined as a sudden, unexpected death caused by loss of heart function. Notwithstanding major developments in the diagnosis and treatment of heart disease, it remains the major contributing factor for deaths. This considers the pattern of sudden cardiac deaths.Methodology: This prospective study was conducted on all cases subjected to medico-legal autopsy in the forensic medicine department at a tertiary care hospital for a period of 18 months. All sudden cardiac deaths satisfying the WHO criteria were included. Unknown cases and bodies in advanced stage of decomposition were excluded.

RESULTS

Sudden cardiac deaths accounted for 55% (82 cases) of 149 cases of sudden natural deaths and 6.5% of total autopsies conducted. The age group most commonly affected by sudden cardiac death ranged from 31 to 50 years. The majority of the cadavers had 90-95% degree of stenosis of left anterior descending artery, 70-80% of right coronary artery and 60-70% left circumflex artery. Coronary insufficiency was the major cause for sudden cardiac deaths with a total of 53 (64.63%) cases.

CONCLUSION

Sudden cardiac deaths accounted for 6.5% of all the autopsies conducted and males outnumbered females with M:F ratio of 10.7:1, with mean age of 44.5 ± 12.63 years. The largest number - 60.97% - were aged between 31 and 50 years. Coronary insufficiency accounted for 64.63% of sudden cardiac deaths.

Computational and experimental studies of Metallo organic framework on human epidermal cell line and anticancer potential

The pentadentate ligand and the precursors were combined to form complexes by green approach. The ligand formation was confirmed by UV-Vis, FT-IR, ¹H-NMR, and LC-MS. The optimised stable structure was obtained by molecular simulation studies and the complexes were interpreted by conductivity measurements, UV-Vis, FT-IR, magnetic susceptibility, VSM, and ESR spectral studies. The redox nature of the complexes was investigated by cyclic voltammetry. The cyclic voltammogram shows complexes exhibited single electron transfer from Cu⁺²/Cu⁺¹. Complexes and penta-dentate ligand were screened for in vitro cytotoxicity by MTT assay method on A431 skin cancer cell line. The ligand structural stability and biological activity were confirmed by theoretical computational studies. The magnetic behaviour showed antiferromagnetic properties at low temperature. The complexes were used as high bar magnets. Similarly, the redox behaviour showed that the complexes could be used in electroplating techniques and sensors. Clinical application revealed that the complexes had effective cytotoxicity. From the data obtained, the complexes were in the form [MLR], where L was the penta-dentate ligand and R = [C₆H₅COO] & R = [C₆H₄COO (OH)].

Anterolateral Thigh Skin and Fascia in Facial Skin Defects with Trismus: Two Problems, One Solution

A case series of five patients with skin loss in the lateral face with trismus that followed delayed presentation following trauma, necrotizing infection, and radiation fibrosis was treated with coronoidectomy and condylar excision to effect adequate mouth opening; the anterolateral thigh flap was used for cover and the fascia was used as an interposition graft to prevent recurrence. Two patients with more than 9 years of follow-up had an average of 40 mm interincisal opening.

α-ZrP Nanoreinforcement Overcomes the Trade-Off between Phosphoric Acid Dopability and Thermomechanical Properties: Nanocomposite HTPEM with Stable Fuel Cell Performance

In recent times, high-temperature polymer electrolyte membranes (HTPEMs) have emerged as viable alternatives to the Nafion-based low-temperature-operated polymer electrolyte membrane fuel cells. This is owing to their higher tolerance to fuel impurities, efficient water management, and higher cathode kinetics. However, the most efficacious HTPEMs such as poly(benzimidazole) (PBI) or 2,5-poly(benzimidazole) (ABPBI), which rely on the extent of phosphoric acid (PA) doping level for fuel cell performance, suffer from poor mechanical properties at higher acid doping levels and dopant leaching during continuous operation. To overcome these issues, we report the synthesis of ABPBI membranes and fabrication of ABPBI-zirconium pyrophosphate (α-ZrP)-based nanocomposite membranes by an ex situ methodology using methane sulfonic acid as the solvent. The incorporation of hydrophilic α-ZrP into the membrane resulted in higher dopability of PA (6.5 mol) and proton conductivity (46 mS/cm) of the membranes (10 wt % of α-ZrP) as against the corresponding values of 3.6 mol and 27 mS/cm, respectively, for the pristine membrane. More remarkably, these property improvements could be achieved while simultaneously augmenting the thermomechanical properties and oxidative stability of the membranes. The unit-cell tests showed a marked improvement in the maximum power density for the nanocomposite membrane (335 mW/cm² at 10 wt % α-ZrP content) over the pristine ABPBI membrane (200 mW/cm²). We also report for the first time the feasibility of a 100 W HTPEM fuel cell (HTPEMFC) stack operated with the nanocomposite membrane with an active area of 39 cm². The HTPEMFC stack delivered a stable voltage and power output, with a voltage drop rate of 0.84 μV/h over a run time of 730 h.

Fatal ruptured ectopic pregnancy - a case report

A 26-year-old unmarried female with a history of acute abdominal pain and bleeding per vagina was brought unresponsive to the hospital. She was in shock on arrival and could not be resuscitated. Death was registered as a medico-legal case. Further investigation by the police revealed that she had amenorrhoea for eight weeks and had tested positive for pregnancy. She had consumed abortion pills purchased from a local pharmacist without consulting a doctor and had developed acute abdominal pain after 48 h. Autopsy revealed a ruptured ectopic pregnancy (tubal type).

Sudden death due to aortic dissection in early pregnancy - a case report

Forensic pathologists come across many deaths due to natural causes which are sudden. Sudden natural deaths in females who are pregnant warrant thorough investigation and a medico-legal autopsy to rule out any foul play. Here, we report a case of 21-year-old primigravida in her first trimester who suddenly complained of severe chest pain and was brought dead to the hospital with no history suggestive of prior natural disease. At autopsy, the death was attributed to dissection of ascending aorta.

Glue sniffing

Inhalant abuse refers to the inhalation of volatile substances for their euphoric effects. Glues and adhesives have been abused inhalants for decades and so the term "glue sniffing" attached to the habit. These days many substances used are not adhesives and the most accurate title of "solvent abuse" has been given to this widespread and dangerous habit. The various methods of inhalational abuse include huffing, bagging, dusting, glading, and sniffing. We report one such case of a 22-year-old male who was found in an unresponsive state at his residence with a plastic cover around his head and empty tubes of "Fevibond" glue beside him. He died on the way to hospital. At autopsy, conjunctival and visceral congestion were found with pulmonary edema and petechiae over visceral pericardium. The viscera were analyzed, and the presence of toluene in his liver and blood was reported.

A death due to ecstasy - a case report

Drug addicts face the dangers of accidental overdose, fatal intoxication, reduced tolerance and carelessness in consuming drugs. There is an increasing use of designer drugs in many cities. The body of a 29 year-old male, an event manager by profession with an alleged history of consumption of ecstasy tablets, was subjected to autopsy. The cause of death was found to be disseminated intravascular coagulation consequent upon consumption of methylenedioxymethamphetamine. This was based on the brief history, autopsy features and a chemical analysis report. This case is discussed with the background of the existing literature about the interplay of the actions of methylenedioxymethamphetamine, the hyperthermia that would result from physical exertion as in dancing in rave parties leading to hyponatremia and the causes of disseminated intravascular coagulation.

Effect of molybdenum and niobium on the phase formation and hardness of nanocrystalline CoCrFeNi high entropy alloys

In the present study, influence of molybdenum and niobium additions on phase formation during mechanical alloying and spark plasma sintering of CoCrFeNi high entropy alloy was studied. Major FCC and minor BCC phase were observed after mechanical alloying of CoCrFeNi. However, major FCC and sigma phase were observed after spark plasma sintering. A maximum relative density of 95% was obtained with the hardness of 570 HV in CoCrFeNi HEA. The phase formation behavior was not significantly affected by the addition of molybdenum or niobium. However, addition of Mo to CoCrFeNi increased the hardness from 570 HV to 620 HV, and the hardness increased to 710 HV with combined addition of molybdenum and niobium. After sintering, major FCC phase with crystallite size of 60-70 nm was observed in all the compositions. Further, the microstructure and hardness retention was observed in CoCrFeNiMo0.2 with annealing temperature up to 800 degrees C.

Sudden death due to coronary artery insufficiency as a result of massive cardiomegaly--a case report

Forensic pathologists encounter a wide range of deaths due to natural causes. Natural deaths can be sudden and unexpected, occurring in apparently healthy people. All such cases have to be investigated and a medico-legal autopsy should be conducted to ascertain the cause of death, and to rule out any criminal cause of death. Here, we report a case of a 46-year-old male who collapsed at his workplace and died. There was no history of significant natural disease. The case was investigated due to the suddenness of his death and absence of a history of significant medical illness. An autopsy revealed that the death was due to coronary artery insufficiency as a result of massive cardiomegaly, although there was absence of significant occlusion of the coronary arteries.

Sudden natural death masquerading as accidental death - a case report

Things are not always what they seem at first sight. One should always be on the watch for more than presents itself as the main issue in the investigation of crime. Whenever a person dies at the scene of accident, it is inferred that the accident caused the death. But that does not mean that the inference is correct. A person who was suspected to have met with a road traffic accident after autopsy turned out to be a case of sudden natural death due to acute haemorrhagic pancreatitis. The case is reported as it is of medico-legal interest because a natural death appeared to be due to a traffic accident.

Bilateral emphysematous pyelitis: a rare encounter in urology

Gas-forming infection of the kidneys can affect either the parenchyma or the collecting system. They are known as emphysematous pyelonephritis (EPN) and emphysematous pyelitis (EP) respectively. Bilateral EPN is a fairly established entity and numerous articles about this condition have been published. However, much less is known about bilateral EP. We report a rare case of bilateral EP and a literature review of this disease. A 66-year-old woman with long-standing bilateral staghorn calculi presented with bilateral EP and severe sepsis. She was treated with antibiotics and bilateral double-J stents to drain the upper urinary tracts. She recovered after 1 month of intensive care and medical therapy. Percutaneous nephrolithotomy (PCNL) had been scheduled to treat her staghorn calculi. A literature search on MEDLINE and Google Scholar with the terms "bilateral emphysematous pyelitis" only found 1 case report in English and another 2 reports in the Korean language that discussed bilateral EP. The collective experience of these few cases, including the present case, suggests that bilateral EP runs a more benign course than bilateral EPN. It should be diagnosed as soon as possible with computed tomography (CT) scans of the renal system. Current evidence shows that can be treated successfully with timely antibiotics. Drainage of the collecting system either percutaneously or with placement of double-J stents might facilitate recovery.

An unusual cause of a penetrating injury to the anterior urethra: a thorny situation

Concurrent penetrating injury to the male external genitalia and the anterior urethra is uncommon. This case illustrates an unusual cause of such an injury, and its subsequent management and outcome. A 69-year-old man had his scrotum and anterior urethra pierced by a long thorn when he fell in his farm. He presented with urine leakage from the scrotal wound each time he micturated. Cystoscopic examination confirmed the cause and extent of the injury, and also facilitated the extraction of the thorn. The injury was allowed time to heal by urinary diversion with a urinary catheter. There were no stricture or fistula formations and the patient remained symptom-free at 3 months follow-up. Careful cystoscopic examination was both diagnostic and therapeutic in this case. A conservative approach is a feasible option in the management of selected cases of penetrating anterior urethral injury.

A rare case of plasmacytoma of the ovary: a case report and literature review

OBJECTIVE

Extramedullary plasmacytomas are rare. Ovarian plasmacytomas, for which treatment options vary, are more unique and even more rare. We will consider the option of optimal cytoreductive surgery followed by adjuvant chemotherapy consisting of carboplatin (AUC-2) to prevent massive ascites and pleural effusion.

CASE REPORT

We report a case of ovarian plasmacytoma in a 35-year-old woman presenting with abdominal pain due to the mass. She underwent optimal cytoreductive surgery. A post-operative histopathologic diagnosis of ovarian plasmacytoma was confirmed. She was assigned stage IIC disease. She received three cycles of single agent carboplatin for rapidly refilling ascites and pleural effusion. Her response was dramatic. There is no evidence of recurrence clinically for more than 14 months. The patient is receiving follow-up care.

CONCLUSION

Multimodality treatment comprising of optimal cytoreductive surgery followed by carboplatin-based chemotherapy is a novel observation and may be an option for the treatment of these rare tumours. This options needs to be further researched.

Ureteric stone in the presence of existing backache: lessons to learn

Incidence of urolithiasis is on the rise due to climatic changes especially global warming.The pain due to presence of ureteric stone is a well known identity but many times it may be asymptomatic or even masked by concurrent presence of backache. In the present article, we describe the case of a 43-year-old male who came to the clinic for treatment of backache persisting for more than two years. The patient complained of backache two years back for which he was treated with analgesics and physiotherapy which relieved his pain. No X-ray was taken earlier because the attending clinician thought the backache to be musculo-skeletal in origin. Recently, one day a sudden episode of backache in the midst of night compelled him to seek medical treatment. However, this time a X-ray was performed and it showed the presence of calculi in the right upper pelvis of ureter which measured 1.9 cm vertically. An ultrasound confirmed the diagnosis. The patient was treated with two episodes of shock wave therapy which failed to crush the stone. A Double-J stent was inserted under general anaesthesia. The stone was crushed using a ureteroscope guided laser. The present case report describes how backache in professionals cannot be lightly attended. Even the characteristic groin to loin pain may be absent. All cases of backache should be properly investigated with an X-ray to rule out renal or ureteric calculi.

Clinicopathological features and survival of testicular tumours in a Southeast Asian university hospital: a ten-year review

INTRODUCTION

Testicular cancer mainly affects young men worldwide. There is lack of published data on patients with this malignant condition from the Southeast Asian region. The aim of this study was therefore to determine the clinicopathologic features of testicular cancer patients treated in a Southeast Asian university hospital and their overall survival rate.

MATERIALS AND METHODS

This was a retrospective study of testicular cancer patients treated between January 2001 and February 2011. Their epidemiological data, clinical presentation, pathologic diagnosis, stage of disease and treatment were gathered and the overall survival rate of this cohort was analyzed.

RESULTS

Thirty-one patients were included in this study. The majority of them were of Malay ethnicity. The average age at presentation was 33.7 years. The commonest testicular cancer was non-seminomatous germ cell tumour, followed by seminoma, lymphoma and rhabdomyosarcoma. More than half of all testicular germ cell tumour (GCT) patients had some form of metastasis at diagnosis. All the patients were treated with radical orchidectomy. Adjuvant chemotherapy was given to those with metastatic disease. Four seminoma patients received radiotherapy to the para-aortic lymph nodes. The 5-year survival rate for all testicular cancers in this cohort was 83.9%. The survival rate was 88.9% in 5 years when GCT were analyzed separately.

CONCLUSION

GCT affects patients in their third and fourth decades of life while lymphoma patients are generally older. Most of the patients treated for GCT are of Malay ethnicity. The majority have late presentation for treatment. The survival rate of GCT patients treated here is comparable to other published series in other parts of the world.

Proptosis: a rare presentation of metastatic renal cell carcinoma

We present a case of a middle-aged man who was incidentally found to have right renal solid mass while investigating for his left eye proptosis. Computerised tomography (CT) scan confirmed the diagnosis of renal cell carcinoma and the tumour was successfully excised via open surgery. The histopathology examination revealed the 10x7x8 cm mass to be a clear cell type renal cell carcinoma. The rare presentation of this metastatic renal cell carcinoma, its diagnosis and management will be discussed.

Clinical Characteristics and Treatment Outcome of Gastrointestinal Non-Hodgkin's Lymphoma

Primary gastrointestinal (GIT) lymphoma constitutes only 5 - 10% of all gastrointestinal tumours. The optimal therapy for these lymphomas is poorly defined and still controversial. We present our experience in the treatment and outcome of primary GIT lymphomas in UKM Medical Center, Malaysia. A retrospective review of all patients with primary GIT lymphoma from the year 2002 until 2007 was done. Our series has shown that primary GIT lymphoma is a rare disease as it comprises only 6.5% of all lymphomas treated in this institution. We had a female predominance of this disease with a large majority at an advanced stage of the disease. There was equal distribution involving stomach, small and large intestines. The incidence of primary GIT lymphomas was 6.5% with a female predominance. The majority had advanced diseases (stage III and IV) with equal distribution involving the stomach, small and large intestines. The most common histological variant was diffuse large B cell lymphoma (66%). Most (83%) patients with intestinal lymphoma had surgical resection and adjuvant chemotherapy. All patients with gastric lymphomas had chemotherapy alone. The mortality rate was 22% predominantly in younger patients with aggressive histology subtypes and advanced disease.

Retrograde intrarenal surgery for renal stones smaller than 2 cm

INTRODUCTION

Extracorporeal shock wave lithotripsy (ESWL) is accepted as the gold standard treatment for renal stones that are smaller than 2 cm. Recently, retrograde intrarenal surgery (RIRS) has been introduced as another form of treatment. We report our experience in dealing with renal stones smaller than 2 cm using RIRS as the primary treatment and following failed ESWL.

METHODS

A retrospective analysis was conducted over a five-year period on patients with stone(s) measuring less than 2 cm each and who had undergone RIRS. The patients were divided into two groups: RIRS as the primary procedure and RIRS post-ESWL.

RESULTS

A total of 46 patients underwent RIRS in our institute. The total stone clearance rate was 61 percent. The clearance rate was better for RIRS as the primary procedure when compared to RIRS as an adjunct procedure (70 percent versus 52 percent; p-value is 0.23). Patients with mid-pole stones achieved an 80 percent stone clearance rate as compared to 60 percent for those with lower pole stones. The clearance rate for upper pole stones was only 29 percent. When RIRS was the primary procedure for lower pole stones, the success rate was 75 percent, compared to 56 percent when it was used as an adjunct procedure post-ESWL.

CONCLUSION

For renal stones measuring less than 2 cm, the stone clearance rate for RIRS was as good as that for EWSL as a primary procedure and achieved a good clearance rate following the failure of ESWL.

WAP(version 2.0): an updated computing and visualization server for water molecules

By exploiting the fast-growing Internet technology, the interactive computing serverWater Analysis Package(WAP, version 2.0) has been updated with more flexible options to better understand the role of the water O atoms present in three-dimensional macromolecular (protein or nucleic acid) structures. The updated robust server facilitates the computation and visualization of water molecules from various hydration shells, interfacial water molecules and those water molecules that stabilize various secondary structural elements. It is also possible to detect the interactions of water molecules with various parts (polar atoms, nonpolar atoms, main-chain and side-chain atoms) of the protein molecule. Furthermore, a molecular graphics visualization program is interfaced to display the nature of the interactions of the water molecules. The Protein Data Bank archive interfaced with the server is updated every week; hence users get to analyse the latest structures. The computing server can be obtained from http://dicsoft2.physics.iisc.ernet.in/wap/.

The TB--Crohn's affair--a never ending dilemma

An 80 year old lady presented with signs and symptoms of sub-acute intestinal obstruction which failed conservative management. CT scan abdomen revealed circumferential ileum thickening with proximal bowel dilatation. Laparotomy and segmental resection was done. Pathological findings were suggestive of chronic granulomatous ileits with differential of Crohn's disease and gastrointestinal tuberculosis. The patient was presumed to have gastrointestinal tuberculosis and commenced on anti tuberculosis treatment despite inconclusive evidence for confirmation and showed marked clinical improvement.

Hairpin RNA-mediated strategies for silencing of tomato leaf curl virus AC1 and AC4 genes for effective resistance in plants

RNA interference (RNAi) using short interfering RNAs (siRNAs) has been widely explored for the suppression of intracellular viral target mRNAs. On the basis of our previous work with stable silencing of Tomato leaf curl virus, in vivo by the antisense replicase gene (AC1) of the virus and characterizing AC4, as a small RNA regulator, besides its role in pathogenicity, we used four different plasmid vector-based siRNA generation strategies to silence viral genes (AC1 and AC4) of tomato leaf curl viruses. The RNAi target sequence were chosen from DNA A of the Tomato leaf curl virus (ToLCV) on the basis of conserved regions in AC1 with an overlapping sequences of the AC4 gene. Different hairpin RNA-mediated strategies like antisense, self-complementary inverted repeats, intron-spliced hairpin RNAs, and small hairpin RNAs were deployed for efficient and predictable resistance to the viruses. Here we present that appropriately designed siRNAs not only prevents RNAi suppression but also help in developing trait-stable transgenics. These strategies imply that ToLCV rep-driven RNAi, targeting AC4 and conserved viral sequences, provides a promising approach to suppress a wide spectrum ToLCV infection in the tomato.

Auxin regulated poly(A)polymerase activity in Cicer arietinum epicotyls

There was a linear increase in poly (A+) polymerase activity in the C. arietinum epicotyls during germination. Six-day-old auxin treated seedlings showed about 3-4 fold stimulation in enzyme activity, accompanied with 3- fold rise in the relative abundance of poly (A+) RNA levels. Actinomycin D, cycloheximide, cordycepin and amino acid analogues caused dramatic decline in poly (A+) polymerase as well as poly (A+) RNA levels. It seems that auxin induced a de novo synthesis of this enzyme.

A dementia story with a happier ending

A case is described of a 77-year-old lady who was diagnosed as having Parkinson's disease and was treated with antiparkinsonian drugs over a year with little effect. She was subsequently referred to a psychiatrist because of her aggressive outbursts and marked changes in personality. Investigations showed that she suffered from normal pressure hydrocephalus (NPH), and the insertion of a ventriculo-peritoneal shunt (VPS) led to a resolution of most of her problems, physical as well as mental.

Brief psychiatric admissions: a review

Concern about mentally ill patients admitted to psychiatric hospitals for short periods is long standing. Often, admission takes place at night when clinical expertise is in short supply. In this study, the researchers found that these patients were admitted to expensive hospital beds not for health needs but often for social reasons. The authors suggest that community-based, short stay psychiatric units are more suitable for the care of these patients.