Healthcare Resource Utilization and Costs in an At-Risk Population With Diabetic Retinopathy

Purpose

Several investigators have suggested the cost-effectiveness of earlier screening, management of risk factors, and early treatment for diabetic retinopathy (DR). We aimed to evaluate the extent of health care utilization and cost of delayed care by insurance type in a vulnerable patient population.

Methods

A retrospective analysis of patients with DR was conducted using electronic medical record (EMR) data from January 2014 to December 2020 at Denver Health Medical Center, a safety net institution. Patients were classified by disease severity and insurance status. DR-specific costs were assessed via Current Procedural Terminology (CPT) codes over a 24-month follow-up period.

Results

Among the 313 patients, a higher proportion of non-English speaking patients were uninsured. Rates of proliferative DR at presentation differed across insurance groups (62% of uninsured, 42% of discount plan, and 33% of Medicare/Medicaid, P = 0.016). There was a significant difference in the total median cost between discount plan patients ($1258, interquartile range [IQR] = $0 - $5901) and both Medicare patients ($751, IQR = $0, $7148, P = 0.037) and Medicaid patients ($593, IQR = $0 - $6299, P = 0.025).

Conclusions

There were higher rates of proliferative DR at presentation among the uninsured and discount plan patients and greater total median cost in discount plan patients compared to Medicare or Medicaid. These findings prioritize mitigating gaps in insurance coverage and barriers to preventative care among vulnerable populations.

Translational Relevance

Advanced diabetic disease and increased downstream health care utilization and cost vary across insurance type, suggesting improved access to preventative care is needed in these specific at-risk populations.

COSMOS: a platform for real-time morphology-based, label-free cell sorting using deep learning

Cells are the singular building blocks of life, and a comprehensive understanding of morphology, among other properties, is crucial to the assessment of underlying heterogeneity. We developed Computational Sorting and Mapping of Single Cells (COSMOS), a platform based on Artificial Intelligence (AI) and microfluidics to characterize and sort single cells based on real-time deep learning interpretation of high-resolution brightfield images. Supervised deep learning models were applied to characterize and sort cell lines and dissociated primary tissue based on high-dimensional embedding vectors of morphology without the need for biomarker labels and stains/dyes. We demonstrate COSMOS capabilities with multiple human cell lines and tissue samples. These early results suggest that our neural networks embedding space can capture and recapitulate deep visual characteristics and can be used to efficiently purify unlabeled viable cells with desired morphological traits. Our approach resolves a technical gap in the ability to perform real-time deep learning assessment and sorting of cells based on high-resolution brightfield images.

Artificial Intelligence-Driven Morphology-Based Enrichment of Malignant Cells from Body Fluid

Cell morphology is a fundamental feature used to evaluate patient specimens in pathologic analysis. However, traditional cytopathology analysis of patient effusion samples is limited by low tumor cell abundance coupled with the high background of nonmalignant cells, restricting the ability of downstream molecular and functional analyses to identify actionable therapeutic targets. We applied the Deepcell platform that combines microfluidic sorting, brightfield imaging, and real-time deep learning interpretations based on multidimensional morphology to enrich carcinoma cells from malignant effusions without cell staining or labels. Carcinoma cell enrichment was validated with whole genome sequencing and targeted mutation analysis, which showed a higher sensitivity for detection of tumor fractions and critical somatic variant mutations that were initially at low levels or undetectable in presort patient samples. Our study demonstrates the feasibility and added value of supplementing traditional morphology-based cytology with deep learning, multidimensional morphology analysis, and microfluidic sorting.

Molecular Glue Discovery: Current and Future Approaches

The intracellular interactions of biomolecules can be maneuvered to redirect signaling, reprogram the cell cycle, or decrease infectivity using only a few dozen atoms. Such "molecular glues," which can drive both novel and known interactions between protein partners, represent an enticing therapeutic strategy. Here, we review the methods and approaches that have led to the identification of small-molecule molecular glues. We first classify current FDA-approved molecular glues to facilitate the selection of discovery methods. We then survey two broad discovery method strategies, where we highlight the importance of factors such as experimental conditions, software packages, and genetic tools for success. We hope that this curation of methodologies for directed discovery will inspire diverse research efforts targeting a multitude of human diseases.

Genome-wide gene expression responses to experimental manipulation of Saccharomyces cerevisiae repressor activator protein 1 (Rap1) expression level

Precise regulation of transcription in gene expression is critical for all aspects of normal organism form, fitness, and function and even minor alterations in the level, location, and timing of gene expression can result in phenotypic variation within and between species including evolutionary innovations and human disease states. Eukaryotic transcription is regulated by a complex interplay of multiple factors working both at a physical and molecular levels influencing this process. In Saccharomyces cerevisiae, the TF with the greatest number of putative regulatory targets is the essential gene Repressor Activator Protein 1 (RAP1). While much is known about the roles of Rap1 in gene regulation and numerous cellular processes, the response of Rap1 target genes to systematic titration of RAP1 expression level remains unknown. To fill this knowledge gap, we used a strain with a tetracycline-titratable promoter replacing wild-type regulatory sequences of RAP1 to systematically reduce the expression level of RAP1 and followed this with RNA sequencing (RNA-seq) to measure genome-wide gene expression responses. Previous research indicated that Rap1 plays a significant regulatory role in particular groups of genes including telomere-proximal genes, homothallic mating (HM) loci, glycolytic genes, DNA repair genes, and ribosomal protein genes; therefore, we focused our analyses on these groups and downstream targets to determine how they respond to reductions in RAP1 expression level. Overall, despite being known as both an activator and as a repressor of its target genes, we found that Rap1 acts as an activator for more target genes than as a repressor. Additionally, we found that Rap1 functions as an activator of ribosomal protein genes and a repressor of the silent mating locus genes consistent with predictions from the literature. Unexpectedly, we found that Rap1 functions as a repressor of glycolytic enzyme genes contrary to prior reports of it having the opposite effect. We also compared the expression of RAP1 to five different genes related to DNA repair pathway and found that decreasing RAP1 downregulated four of those five genes. Finally, we found no effect of RAP1 depletion on telomere-proximal genes despite its functioning to silence telomeric repeat-containing RNAs. Together our results enrich our understanding of this important transcriptional regulator. The graphical abstract is provided as a supplementary fig. (S-Fig 1).

Vacuum-Assisted Closure Treats Refractory Esophageal Leak in a Pediatric Patient

Esophageal perforations can have iatrogenic and non-iatrogenic causes. Early identification is a predictor of good outcomes. When identified, perforations can be managed conservatively with wide drainage or repaired surgically. Endoscopic esophageal vacuum-assisted closure may be used as a definitive treatment, particularly in scenarios where conservative management and primary surgical repair fail to achieve complete healing. We present such a scenario advocating for the consideration of endoscopic esophageal vacuum-assisted closure in patients with refractory esophageal leaks.

111 Adipose Tissue-Derived Mesenchymal Stem Cells as a Potential Restorative Treatment for Cartilage Defects: A PRISMA Review and Meta-Analysis

Aim

Joint damage through trauma or degeneration causes cartilage defects, leading to osteoarthritis (OA). Current therapies relieve symptoms or replaces damaged joint, which is costly and fraught with complications. Mesenchymal stem cells (MSCs) have immunomodulatory properties and low immunogenicity, making them a novel avenue for research for OA treatment. This systematic review investigates whether adipose derived MSC (AMSCs) can treat cartilage defects.

Method

A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, Scopus, Web of Science. Clinical, imaging, functional outcomes were extracted from nineteen included studies. Inclusion criteria was studies conducted on human populations that compared effects of AMSCs on cartilage regeneration to non-exposed controls. Studies conducted on animals, ex vivo studies, in vitro studies were excluded.

Results

Nine studies reported improved Visual Analogue Scale (VAS) scores (mean difference -3.30; 95% CI:-3.72,-2.89; p<0.001). Eight studies reported improved Knee injury and Osteoarthritis Outcome Score (KOOS) in five subscales. Pooled analysis of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores in seven studies revealed an improvement (mean difference -25.52; 95% CI:-30.93,-20.10; p<0.001). Cartilage regeneration was assessed using Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. All studies reported improved regeneration, with a pooled end-point score of 68.12 (95% CI:62.18–74.05; p<0.001).

Conclusions

AMSCs are effective therapeutic agents for cartilage defects. We recommend researchers to determine roles of biochemical components that facilitate AMSC-mediated cartilage repair. Establishing the most efficient methods for MSC extraction, culture, delivery, and performing studies with long follow-up times enable future research to provide evidence needed to bring AMSC-based therapies into the market.

180 Retrograde Hindfoot Nailing for the Treatment of Acute Ankle Fractures in the Elderly - a Systematic Review and Meta-Analysis

Aim

Fragility ankle fractures are traditionally managed conservatively or with open reduction internal fixation (ORIF). Tibiotalocalcaneal (TTC) nailing is an alternative option for the geriatric patient. This meta-analysis provides the most detailed analysis of hindfoot nailing for fragility ankle fractures.

Method

A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, Scopus, Web of Science, identifying fourteen studies for inclusion. Studies including patients over 60 with a fragility ankle fracture, treated with TTC nail were included. Patients with a previous fracture of the ipsilateral limb, fibular nails, and pathological fractures were excluded.

Meta-regression analyses were performed to explore sources of heterogeneity, and publication bias was assessed using Egger's test.

Results

312 ankle fractures were included. The mean age was 77.3 (32–101) years. 26.9% were male, and 41.9% were diabetics. The pooled proportion of superficial infection, deep infection, implant failure, malunion, and all-cause mortality was 0.10 (95%CI:0.06–0.16; I2=44%), 0.08 (95%CI:0.06–0.11, I2=0%), 0.11 (95%CI:0.07–0.15,I2=0%), 0.11 (95%CI:0.06–0.18; I2=51%), and 0.27 (95%CI:0.20–0.34; I2=11%), respectively. The pooled mean post-operative OMAS score was 54.07 (95%CI:48.98–59.16; I2=85%). The best-fitting meta-regression model included age and percentage of male patients as covariates (p=0.0263), and were inversely correlated with higher OMAS scores. Egger's test (p=0.56) showed no significant publication bias.

Conclusions

TTC nailing is an adequate alternative option for fragility ankle fracture management. However, current evidence includes mainly case series with inconsistent outcome measures reported and post-operative rehabilitation protocols. Prospective RCTs with long follow-up times and large cohort sizes are needed to clearly guide the use of TTC nailing for ankle fractures.

893 Predictors for Infection Severity in Open Tibial Fractures

Aim

Open tibial fractures can be difficult to manage - many factors could affect treatment and outcome, including being complicated by infection. We present a cohort of 244 patients and analyse which factors are significantly associated with infection outcome.

Method

Open tibia fractures treated at a major trauma centre between 2015–2021 were included.

Infection status was categorized into no infection, superficial infection, osteomyelitis. Data collected were Age, mode of injury, polytrauma, fibula status, Gustilo-Anderson (GA) classification, wound contamination, time to first procedure. time to definitive plastics procedure, time to definitive fixation, type of definitive fixation, smoking/diabetic status, and BMI.

Multicollinearity was calculated, with highly correlated factors removed. Multinomial logistic regression was performed. Chi-Squared test, with Post-Hoc Bonferroni correction was performed for complex categorical factors.

Results

244 patients were included. Polytrauma and fibula status, and type of definitive fixation were excluded from the multivariate model due to strong multicollinearity. Compared to non-infected outcome, patients with superficial infection had higher BMI (p<0.01), higher GA grade (p<0.01), and osteomyelitis patients had longer time to definitive fixation (p=0.049) and longer time to definitive plastics procedure (p=0.013), higher GA grade, and wound contamination.

Post-hoc analysis showed “no infection” was positively associated with GA-I (p=0.029) and GA-II (p<0.01), and negatively associated with GA-IIIC (p<0.01). Osteomyelitis was positively associated with GA-IIIc (p<0.01)

Conclusions

This study investigated associations between injury and presentation factors that may have been associated with infection. We suggest clinicians should give extra consideration to the factors highlighted during management and take preventative measures to mitigate the infection risk.

114 Bone Transport Using the Monorail External Fixator Over an Intramedullary Nail for Post-Traumatic Femoral Defects

Aim

The management of limb-length discrepancy secondary to traumatic bone loss poses a unique challenge for surgeons. The Ilizarov technique is popular but is associated with long external fixator time and many complications. This retrospective study assessed outcomes of post-traumatic femoral defects managed by monorail external fixation over an intramedullary nail.

Method

Eight patients were included from over a four-year period with post-traumatic femoral defects, that underwent treatment with monorail fixator-assisted intramedullary nailing. Mean follow-up time was 232.83 weeks. Five were open fractures (Gustilo-Anderson type 3A:n=4, 3B:n=1), one had closed fracture. Average bone defect size was 8cm. Primary outcomes were lengthening index, consolidation time and index, external fixator index. Secondary outcomes were time to full weight bearing(FWB), time to union, complications. Patient reported outcome measures including EQ-5D-5L, SF-36, Oxford knee scores(OKS), Oxford hip scores(OHS) were recorded after recovery.

Results

Average consolidation time and index were 11.35months and 1.24months/cm, respectively. Mean lengthening and external fixator index were 20.2days/cm and 23.88days/cm, respectively. On average, patients achieved FWB and bone union 56.25 weeks and 68.83 weeks after bone transport initiation, respectively. Two patients had docking site non-union, treated by reamed intramedullary exchange nailing. Two patients had osteomyelitis. EQ-5D-5L and EQ-VAS scores were compared to UK population norms (p=0.104, p=0.238, respectively). Average OKS was 32.17 and OHS was 34.00.

Conclusions

Monorail external fixation over an intramedullary nail is an effective option for post-traumatic femoral defects, reducing external fixator time, lowering complication rate, returning patients’ quality of life to a level comparable with the normal population.

245 Ankle Fusion with Tibiotalocalcaneal Retrograde Nail for Fragility Ankle Fractures: Outcomes at a Major Trauma Centre

Aim

Fragility ankles fractures in the geriatric population are challenging to manage, due to fracture instability, soft tissue compromise, and patient co-morbidities. Traditional management options include open reduction internal fixation, or conservative treatment, both of which are fraught with high complication rates. We aimed to present functional outcomes of elderly patients with fragility ankle fractures treated with retrograde ankle fusion nails.

Method

171 patients received a tibiotalocalcaneal nail over a six-year period, but only twenty met the inclusion criteria of being over sixty and having poor bone stock. Primary outcome was mortality risk from co-morbidities according to Charlson co-morbidity index (CCI), and patients’ post-operative mobility status compared to pre-operative mobility. Secondary outcomes include intra-operative and post-operative complications, six-month mortality rate, time to mobilisation and union.

Results

Mean age was 77.82 years old. The average CCI was 5.05. Thirteen patients returned to their pre-operative mobility state. Patients with low CCI are more likely to return to pre-operative mobility status (p=0.16;OR=4.00).

Average time to bone union and mobilisation were 92.5 days and 7.63 days, respectively. Mean post-operative AOFAS ankle-hindfoot and Olerud-Molander scores were 53.0 and 50.9, respectively. There were four cases of superficial infection. Patients with high CCI were more likely to acquire superficial infections (p=0.264,OR=3.857). There were no deep infections, periprosthetic fractures, nail breakages, non-unions. Average follow-up time was 499.3 days.

Conclusions

Tibiotalocalcaneal nailing is an effective and safe option for managing fragility ankle fractures in the elderly. This technique leads to lower complication rates and earlier mobilisation than traditional fixation methods.

Physician Electronic Health Record Usage as Affected by the COVID-19 Pandemic

OBJECTIVES

To utilize metrics from physician action logs to analyze volume, physician efficiency and burden as impacted by telemedicine implementation during the COVID-19 (coronavirus disease 2019) pandemic, and physician characteristics such as gender, years since graduation, and specialty category.

METHODS

We selected 11 metrics from Epic Signal, a functionality of the Epic electronic health record (EHR). Metrics measuring time spent in the EHR outside working hours were used as a correlate for burden. We performed an analysis of these metrics among active physicians at our institution across three time periods-prepandemic and telehealth implementation (August 2019), postimplementation of telehealth (May 2020), and follow-up (July 2020)-and correlated them with physician characteristics.

RESULTS

Analysis of 495 physicians showed that after the start of the pandemic, physicians overall had fewer appointments per day, higher same day visit closure rates, and spent less time writing notes in the EHR outside 7 a.m. to 7 p.m. on patient scheduled days. Across all three time periods, male physicians had better EHR-defined "efficiency" measures and spent less time in the EHR outside working hours. Years since graduation only had modest associations with higher same day visit closure rates and appointments per day in May 2020. Specialty category was significantly associated with appointments per day and same day closure visit rates and also was a significant factor in the observed changes seen across the three time periods.

CONCLUSION

Utilizing EHR-generated reports may provide a scalable and nonintrusive way to monitor trends in physician usage and experience to help guide health systems in increasing productivity and reducing burnout.

Protocol for germ lineage differentiation of primed human pluripotent stem cells using chemically defined, nutrient-balanced media

Metabolism regulates cell fates during early mammalian cell differentiation. This protocol describes the steps for directed differentiation of primed human pluripotent stem cells (hPSCs) into the three primary germ lineages-ectoderm, endoderm, and mesoderm-using a chemically defined nutrient-balanced media formulation. Although the transient removal and addition of specific nutrients does not occur in vivo during embryonic development, manipulation of nutrients in vitro provides an accessible method for evaluating how extracellular and intracellular metabolites help determine hPSC fate. For complete details on the use and execution of this protocol, please refer to Lu et al. (2019) and Lu et al. (2022).

Chronic kidney damage pathology score for systematic assessment of the non-neoplastic kidney tissue and prediction of post-operative renal function outcomes

To establish a systematic histological assessment of non-neoplastic kidney (NNK) tissue at the time of nephrectomy to evaluate a patient's risk of developing post-operative renal dysfunction, a combined prospective pathologic assessment of the NNK and a retrospective clinical chart review was conducted. A blinded nephropathologist performed standardized assessment of glomerular sclerosis, tubulointerstitial fibrosis, arteriosclerosis, and hyaline arteriolosclerosis. Combined these formulated the chronic kidney damage pathology score (CKDPS). Multivariate logistic regression models were developed to assess the effect of CKDPS and other clinical factors on renal function up to 24 months following nephrectomy (partial or radical). 156 patients were included in the analysis with a median age of 60 years. 70% patients underwent radical nephrectomy. A history of hypertension and/or diabetes was present in 55.8% and 22.1%, respectively. Higher CKDPS (particularly glomerular global sclerosis and arteriosclerosis scores), radical nephrectomy, and reduced baseline estimated glomerular filtration rate (eGFR) were associated with worsening post-operative renal function outcomes. The systematic assessment of non-neoplastic kidney tissue at the time of renal surgery can help identify patients at risk of post-operative renal dysfunction. CKDPS represents a standardized and prognostically relevant histologic reporting system for non-neoplastic kidney tissue.

Glutamine-dependent signaling controls pluripotent stem cell fate

Human pluripotent stem cells (hPSCs) can self-renew indefinitely or can be induced to differentiate. We previously showed that exogenous glutamine (Gln) withdrawal biased hPSC differentiation toward ectoderm and away from mesoderm. We revealed that, although all three germ lineages are capable of de novo Gln synthesis, only ectoderm generates sufficient Gln to sustain cell viability and differentiation, and this finding clarifies lineage fate restrictions under Gln withdrawal. Furthermore, we found that Gln acts as a signaling molecule for ectoderm that supersedes lineage-specifying cytokine induction. In contrast, Gln in mesoderm and endoderm is the preferred precursor of α-ketoglutarate without a direct signaling role. Our work raises a question about whether the nutrient environment functions directly in cell differentiation during development. Interestingly, transcriptome analysis of a gastrulation-stage human embryo shows that unique Gln enzyme-encoding gene expression patterns may also distinguish germ lineages in vivo. Together, our study suggests that intracellular Gln may help coordinate differentiation of the three germ layers.

Nutrients in the fate of pluripotent stem cells

Pluripotent stem cells model certain features of early mammalian development ex vivo. Medium-supplied nutrients can influence self-renewal, lineage specification, and earliest differentiation of pluripotent stem cells. However, which specific nutrients support these distinct outcomes, and their mechanisms of action, remain under active investigation. Here, we evaluate the available data on nutrients and their metabolic conversion that influence pluripotent stem cell fates. We also discuss key questions open for investigation in this rapidly expanding area of increasing fundamental and practical importance.

537 Open vs Closed Pilon Fractures: Comparison of Management, Outcomes, and Complications

Aim

Despite the low incidence of pilon fractures, their high impact nature presents difficulties in surgical management/recovery. Current literature is varied, with no universal treatment algorithm. We aim to highlight differences in treatment, outcomes, complications between open and closed pilon fractures.

Method

This retrospective study was conducted at a major trauma centre, including patients over 5-year period. 135 patients were included (open:48, closed:87). Primary outcome was AOFAS score at 3-, 6- and 12-months post-injury. Secondary outcomes include time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time, follow-up time. Post-operative complications were collected.

Results

Open fractures had lower AOFAS score 3 months post-injury, longer bone union time, and time to FWB. For both open and closed fractures, compared to ORIF patients, those treated with fine wire fixator (FWF) had lower AOFAS scores 3- and 6-months post-injury. Closed fracture patients treated with ORIF had shorter bone union time, time to PWB and FWB. Patients with AO/OTA 43A fractures needed shorter time to PWB and FWB than those with 43C fractures. Common complications (closed:open) were superficial infection (22%:54%), post-traumatic arthritis (25%:16%), non-union (11%:24%).

Conclusions

Open fractures, with more extensive soft tissue damage, were likely more suited for FWF, rather than ORIF (18% of open vs 72% of closed were treated with ORIF). Due to greater associated trauma, more frequent complications, and delayed definitive fixation, open fractures had lower AOFAS scores. Nevertheless, use of staged approach involving temporary external fixation, followed with ORIF or FWF achieved low complication rates and good functional recovery.

FEMA GRAS assessment of natural flavor complexes: Origanum oil, thyme oil and related phenol derivative-containing flavoring ingredients

In 2015, the Expert Panel of the Flavor and Extract Manufacturers Association (FEMA) initiated a re-evaluation of the safety of over 250 natural flavor complexes (NFCs) used as flavor ingredients, mostly consisting of a variety of essential oils and botanical extracts. This publication, seventh in the series, re-evaluates NFCs with constituent profiles dominated by phenolic derivatives including carvacrol, thymol and related compounds using a constituent-based procedure first published in 2005 and updated in 2018. The procedure is based on the chemical characterization of each NFC as intended for commerce and the estimated intake of the constituent congeneric groups. The procedure applies the threshold of toxicological concern (TTC) concept and evaluates relevant data on absorption, metabolism, genotoxic potential and toxicology of the constituent congeneric groups and the NFC under evaluation. Herein, the FEMA Expert Panel affirmed the generally recognized as safe (GRAS) status of seven phenolic derivative-based NFCs, Origanum Oil (Extractive) (FEMA 2828), Savory Summer Oil (FEMA 3013), Savory Summer Oleoresin (FEMA 3014), Savory Winter Oil (FEMA 3016), Savory Winter Oleoresin (FEMA 3017), Thyme Oil (FEMA 3064) and Thyme White Oil (FEMA 3065) under their conditions of intended use as flavor ingredients.

A System for the Evolution of Protein-Protein Interaction Inducers

Molecules that induce interactions between proteins, often referred to as "molecular glues", are increasingly recognized as important therapeutic modalities and as entry points for rewiring cellular signaling networks. Here, we report a new PACE-based method to rapidly select and evolve molecules that mediate interactions between otherwise noninteracting proteins: rapid evolution of protein-protein interaction glues (rePPI-G). By leveraging proximity-dependent split RNA polymerase-based biosensors, we developed E. coli-based detection and selection systems that drive gene expression outputs only when interactions between target proteins are induced. We then validated the system using engineered bivalent molecular glues, showing that rePPI-G robustly selects for molecules that induce the target interaction. Proof-of-concept evolutions demonstrated that rePPI-G reduces the "hook effect" of the engineered molecular glues, due at least in part to tuning the interaction affinities of each individual component of the bifunctional molecule. Altogether, this work validates rePPI-G as a continuous, phage-based evolutionary technology for optimizing molecular glues, providing a strategy for developing molecules that reprogram protein-protein interactions.

Dietary administration of β-ionone epoxide to Sprague-Dawley rats for 90 days

In a 90-day GLP-compliant study groups of Sprague-Dawley rats (10/sex/group) were fed diets containing β-ionone epoxide, a fragrance material and a flavoring substance, at dietary concentrations providing target intakes of 0, 20, 40 and 80 mg/kg bw/day. There were no deaths and no adverse changes in clinical observations, ophthalmological examinations, body weight, body weight gain, food consumption, food efficiency; hematology, serum chemistry, urinalysis parameters; or in macroscopic findings attributable to β-ionone epoxide administration. Increased absolute and relative liver weights in high dose females without correlating hepatic histopathological findings were considered non-adverse. Cortical vacuolation of adrenal zona fasciculata was observed in high-dose males but was considered non-adverse due to the nondegenerative nature of this alteration. β-Ionone epoxide did not influence estrus cyclicity in females and did not affect sperm morphology or epididymal sperm count, homogenization-resistant spermatid count and motility measurements in male rats. The no-observed-adverse-effect level (NOAEL) for administration of β-ionone epoxide in the diet was determined to be the highest dose tested of 80 mg/kg bw/day.

Electronic Health Record Usage Patterns: Assessing Telemedicine's Impact on the Provider Experience During the COVID-19 Pandemic

Telemedicine has been widely implemented during the coronavirus disease 2019 (COVID-19) pandemic; however, its impact on those providing care remains largely understudied. Provider documentation data collected by the electronic health record (EHR) represents an underutilized tool for assessing the provider experience. Through Epic Signal, we collected data regarding the actions logged in the EHR by health care providers of the Montefiore Health System (Bronx, NY) before and after the implementation of telemedicine during the pandemic. Focusing on five metrics (appointments per day, visits closed same day, time spent outside 7 AM-7 PM, time spent on unscheduled days, and pajama time), we performed a preliminary analysis of providers across the institution, by specialty, and according to demographic characteristics such as gender and years since graduation. We observed that after telemedicine implementation, a greater proportion of providers had fewer appointments per day, closed more notes same day, and spent less time in the EHR outside of normal working hours for each of the time-related metrics. We additionally found that providers who graduated longer ago as well as female providers spent more time documenting in the EHR after hours. This brief analysis highlights the potential of using EHR data to inform decisions based on provider well-being, specifically in the setting of telemedicine implementation.

Rural, urban, and teaching hospital differences in hip fracture mortality

Introduction

Hip fractures remain one of the most prevalent and deadly conditions afflicting those 65 years and older. For other health conditions (e.g. myocardial infarction), hospital location is associated with poorer health outcomes. To our knowledge, no study has investigated the relationship between hip fracture morality rate in the United States between urban and rural hospital settings.

Methods

A retrospective cohort study was conducted to examine differences in in-hospital mortality between groups treated in rural, urban-teaching, and urban-non-teaching hospitals, as well as public and private hospitals. Mortality rates were also compared for variances between surgical treatment, sex, insurance, patient location, race, and income. Discharge data was collected for 256,240 inpatient stays from the 2012 National Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality.

Results

Odds of mortality were 14.6% greater in rural hospital hip fracture patients compared to Urban/Non-Teaching centers (p < 0.05).

Conclusions

Results from this study lend support to necessitate further research investigating prospective barriers to care of those in rural settings. This may point to limitations in resources and trained medical and surgical specialists in rural hospitals and need for continued research to mitigate such findings.

Absence of mutagenic activity in the bacterial reverse mutation assay with pulegone and peppermint oil

The essential oil of peppermint and one of its natural constituents, (R)-(+)-pulegone, are approved flavorings added to food worldwide. (R)-(+)-Pulegone and peppermint oil were tested separately in two independent bacterial reverse mutation assays according to Organisation for Economic Co-operation and Development Guideline 471. Both flavorings did not produce any evidence of mutagenicity up to cytotoxic concentrations in either the presence or the absence of exogenous metabolic activation.

Dietary administration of β-caryophyllene and its epoxide to Sprague-Dawley rats for 90 days

Two independent 90-day GLP-compliant studies were conducted in Sprague-Dawley rats with β-caryophyllene or β-caryophyllene epoxide, two common flavoring and fragrance materials. Dietary concentrations of β-caryophyllene were 3500; 7000; and 21,000 ppm for males and 3500; 14,000; and 56,000 ppm for females. Dietary concentrations of β-caryophyllene epoxide were 1750; 10,500; and 21,000 ppm. There were no deaths or clinical toxicity attributable to either substance administration. Statistically significant, dose-dependent reductions in body weight, body weight gain, food consumption, and food efficiency at the highest dietary concentrations of β-caryophyllene, but not of β-caryophyllene epoxide, were attributed to palatability issues. Neither β-caryophyllene nor β-caryophyllene epoxide influenced estrus cyclicity or sperm parameters. Macroscopic and microscopic findings were primarily related to changes in the kidneys of male rats, consistent with α2u-globulin nephropathy, and in the liver of male and female rats, including hepatocyte hypertrophy at the middle and high intake levels. These changes correlated with increased absolute and relative organ weights. Since the kidney findings were a species- and sex-specific effect, the NOAEL in each study was based on hepatocyte hypertrophy at the two highest dietary concentrations and were determined to be 222 mg/kg bw/day for β-caryophyllene and 109 mg/kg bw/day for β-caryophyllene epoxide.

2,4-Decadienal does not induce genotoxic effects in in vivo micronucleus studies

2,4-Decadienal (E,E-) occurs naturally in foods and is also used as a flavoring ingredient. In vivo micronucleus studies were used to evaluate the potential for 2,4-decadienal to cause genotoxic effects. Male Han Wistar rats were dosed either by intraperitoneal injection or by gavage in two independent studies. The animals (12/group) received 25, 50, or 100 mg/kg bw of 2,4-decadienal via intraperitoneal injection, or 350, 700, or 1400 mg/kg bw via gavage. Dose-dependent decreases in the percentages of peripheral blood reticulocytes were observed in both studies, indicating that the target tissue was exposed to toxic levels of 2,4-decadienal. No induction of micronuclei in the bone marrow polychromatic erythrocytes or the peripheral blood reticulocytes was observed in either study. These results, coupled with previous mutagenicity studies, support the overall conclusion that 2,4-decadienal does not present a concern for genotoxicity.

New Service Model for Common Mental Disorders in Hong Kong: a Retrospective Outcome Study

OBJECTIVE

To review the first 8-month outcome of the Common Mental Disorder Clinic model in Hong Kong in terms of patient exit status and improvement in depressive and anxiety symptoms.

METHODS

During the first appointment, patients were interviewed by a multidisciplinary team comprising a psychiatrist, a psychiatric nurse, and an occupational therapist. A multidisciplinary case conference was conducted to discuss clinical observations, diagnosis, issues of concern, and the optimal individualised treatment plan. Low-intensity interventions by nurses and/or occupational therapists were provided, as were optional, time-limited, protocol-based interventions by clinical psychologists for those with mild to moderate depressive and anxiety symptoms. Pharmacological intervention may be used when indicated. Upon completion of the treatment plan, patients were reassessed by the treating psychiatrist. Discharge options included discharge without psychiatric follow-up, step-up to psychiatric outpatient clinics, and step-down services. The self-administered Patient Health Questionnaire-9 (PHQ-9) and Generalised Anxiety Disorder 7-item scale (GAD-7) were used to assess the past 2 weeks' depressive and anxiety symptoms, respectively, at baseline and at each session.

RESULTS

From July 2015 to February 2016, 1325 Chinese patients received the new service. Of them, 170 men and 363 women (mean age, 52.6 years) completed the treatment plan. After treatment, their mean PHQ-9 score decreased from 11.06 to 7.55 (p < 0.001), and the mean GAD-7 score decreased from 9.94 to 6.54 (p < 0.001). After treatment, 42.4% and 48.2% of the patients were within the normal range of PHQ-9 and GAD-7 scores, respectively, compared with 16.9% and 20.8% before treatment. The mean time to implementation of the individualised treatment plan was 82.33 days. Of the patients, 54.4% were discharged without any need for medical or psychiatric follow-up; 28% were stepped up to psychiatric outpatient clinics; and 17.3% were stepped down. The predictors of exit status were whether psychiatric medication was prescribed during initial intake (p = 0.011), whether psychiatric medication was prescribed at last follow-up (p < 0.001), the service period (p = 0.010), and the GAD-7 final score (p = 0.005).

CONCLUSIONS

The first 8-month outcome of the new service model was encouraging, with shortened waiting time, reduced severity of symptoms, and better exit status (high recovery and step-down rates).

Quality and Quantity in Kidney Cancer Surgery: The Role of Nonneoplastic Kidney and Kidney Volumetrics in Predicting Postoperative Renal Function

Objectives

To model renal function 2 years following radical nephrectomy with quantitative analyses using clinical, histopathologic, and renal composite cortical volumes (CCV).

Methods

This retrospective study involved an assessment of the nonneoplastic kidney tissue by three blinded nephropathologists using modified Banff 1997 criteria for renal allograft pathology. Volumetric image acquisition was obtained by three independent radiologists using preoperative imaging. A 2-year estimated glomerular filtration (eGFR) calculator was created.

Results

Among the 126 patients, median age was 60 years; median CCV, 398.1 cm3; preoperative eGFR, 77 mL/min/1.73 m2; and 2-year postoperative eGFR, 54 mL/min/1.73 m2. Of the subjects, 64% had hypertension, 26% diabetes, and 37% were smokers. Increasing age, glomerulopathy/sclerosis, tubulointerstitial scarring, and arteriosclerosis were statistically significantly and adversely associated with eGFR. Conversely, increasing CCV was associated with a higher eGFR.

Conclusions

Quantitative analysis of the nephrectomized kidney in conjunction with patient age can accurately predict renal function at 2 years.

Metabolism in pluripotency: Both driver and passenger?

Pluripotent stem cells (PSCs) are highly proliferative cells characterized by robust metabolic demands to power rapid division. For many years considered a passive component or "passenger" of cell-fate determination, cell metabolism is now starting to take center stage as a driver of cell fate outcomes. This review provides an update and analysis of our current understanding of PSC metabolism and its role in self-renewal, differentiation, and somatic cell reprogramming to pluripotency. Moreover, we present evidence on the active roles metabolism plays in shaping the epigenome to influence patterns of gene expression that may model key features of early embryonic development.

Metabolism in Pluripotent Stem Cells and Early Mammalian Development

Emerging and seminal studies have shown that cell metabolism influences gene expression by modifying the epigenome, which can regulate stem cell pluripotency, differentiation, and somatic cell reprogramming. Core pluripotency factors and developmental regulators reciprocally control the expression of key metabolism genes and their encoded pathways. Recent technological advances enabling sensitive detection methods during early mammalian development revealed the state-specific and context-dependent coordination of signal transduction, histone modifications, and gene expression in developing, resting, and malnourished embryos. Here, we discuss metabolism as a potential driver of earliest cell fate through its influence on the epigenome and gene expression in embryos and their in vitro surrogate pluripotent stem cells.

The safety of intracytoplasmic sperm injection and long-term outcomes

The pioneering of intracytoplasmic sperm injection (ICSI) approximately 25 years ago revolutionized the treatment of infertile couples. Today, ICSI remains an indispensable part of assisted reproductive treatments (ART) and has resulted in the birth of millions of babies. The 25th anniversary of ICSI marks a chronologic landmark in its evolving history. This landmark also serves as an opportunity to thoroughly appraise the safety of ICSI and analyze the long-term outcomes of ICSI-conceived children. In this review, we collate and analyze salient data accrued over the past 25 years pertaining to the long-term safety of ICSI and ICSI conceptions. We also evaluate the effects of ICSI on the perinatal outcomes, congenital malformation rates, cognitive development and reproductive health of ICSI-conceived neonates, children, adolescents and adults, respectively. In doing so, we also highlight the existence of potential confounders and biases that frequently obscure the interpretation of clinical follow-up studies.

Identification of novel genes and transcription factors involved in spleen, thymus and immunological development and function

We constructed and analyzed six serial analysis of gene expression (SAGE) libraries to identify genes with previously uncharacterized roles in spleen or thymus development. A total of 625 070 tags were sequenced from the three spleen (embryonic day (E)15.5, E16.5 and adult) and three thymus (E15.5, E18.5 and adult) libraries. These tags corresponded to 83 182 tag types, which mapped unambiguously to 36 133 different genes. Genes over-represented in these libraries, compared to 115 mouse SAGE libraries (www.mouseatlas.org), included genes of known and unknown immunological or developmental relevance. The expression profiles of 11 genes with unknown roles in spleen and thymus development were validated using reverse transcription-qPCR. We further characterized the expression of one of these candidates, RIKEN cDNA 9230105E10 that encodes a murine homolog of Trim5alpha, in numerous adult tissues and immune cell types. In addition, we demonstrate that transcript levels are upregulated in response to TLR stimulation of plasmacytoid dendritic cells and macrophages. This work provides the first evidence of regulated and cell type-specific expression of this gene. In addition, these observations suggest that the SAGE libraries provide an important resource for further investigations into the molecular mechanisms regulating spleen and thymus organogenesis, as well as the development of immunological competence.

A novel approach of intravenous electrocardiograph technique in correct position the long-term central venous catheter

Intravenous electrocardiograph (IVECG) can correctly positioning the catheter tip by enlarging p wave as it is moved toward right atrium, and it is a safe, reliable and accurate technique. To evaluate the efficacy of wire-conducted IVECG signal and IVECG signal from the port with sodium bicarbonate (NaHCO3) flushed catheter and to compare those with conventional anatomy landmark method was the propose of this study. This prospective study was carried out in 216 patients who suffered from malignant diseases. The correct position of the catheter tip among these groups was confirmed as follows. In group 1 (n = 80), the anatomy landmark method and portable chest radiograph recognized the correct position. In group 2 (n = 72), IVECG signal was conducted from guide wire to identify the tip position. In group 3 (n = 64), IVECG signal was conducted from the port with NaHCO3 (0.8 mEq/mL) flushed catheter to ascertain the tip position. The patient characteristics did not differ significantly among the groups. The duration of operation was significantly (P < 0.001) longer in group 1 than in group 2 and group 3 (45.4 +/- 9.3 minutes vs 35.7 +/- 8.0 minutes and 35.2 +/- 9.7 minutes, respectively). Catheter tip placement times were shorter in group 2 and group 3 than in group 1 (5.3 +/- 2.9 minutes and 6.4 +/- 3.0 minutes vs 16.7 +/- 5.7 minutes, respectively); there was a statistically significant difference between the group 1 and group 2 and group 3 (p < 0.001). Nonetheless, the duration of operation and catheter tip placement time was similar in group 2 and group 3. Early and late complications within the subsequent 3 months showed no significant difference among groups. We concluded that IVECG signal conducted from guide wire obtained a similar efficiency to that signal from the port with NaHCO3 flushed catheter on positioning the catheter tip of the venous Port-A-Cath system. It is recommended to use these methods to facilitate implanting long-term central venous devices.

One-stage microneurovascular free abductor hallucis muscle transplantation for reanimation of facial paralysis

We introduce a new method using abductor hallucis muscle free transplantation for reanimation of the cheek with long-standing facial palsy in six young patients. The muscle is used to reanimate facial palsy because it has many unique advantages: (1) appropriate size and shape of the muscle and adequate bulk, (2) closely parallel alignment and unvaried anatomy of the main vessels and nerve distribution to the muscle, (3) a long neurovascular pedicle, (4) easy surgical isolation of the muscle and its neurovascular pedicle, and (5) no functional deficit after muscle removal. The nerve and muscle grafts can be performed by microneurovascular anastomosis in one surgical procedure. The follow-up period was over 1 year. A satisfactory result was obtained in five of six patients.

Microvascular free flap based on the medial femoral main cutaneous artery

This article introduces a free flap based on the medial femoral main cutaneous artery. Flap transfer was carried out in two cases with complete postoperative success. An anatomical description of the midportion of the medial femoral region, based on magnification and binocular dissection microscope studies is provided, and the operative procedure is described.