Socio-demographic and clinical characteristics of re-presentation to an Australian inner-city emergency department: implications for service delivery

BACKGROUND: People who have complex health care needs frequently access emergency departments for treatment of acute illness and injury. In particular, evidence suggests that those who are homeless, or suffer mental illness, or have a history of substance misuse, are often repeat users of emergency departments. The aim of this study was to describe the socio-demographic and clinical characteristics of emergency department re-presentations. Re-presentation was defined as a return visit to the same emergency department within 28 days of discharge from hospital. METHODS: A retrospective cohort study was conducted of emergency department presentations occurring over a 24-month period to an Australian inner-city hospital. Characteristics were examined for their influence on the binary outcome of re-presentation within 28 days of discharge using logistic regression with the variable patient fitted as a random effect. RESULTS: From 64,147 presentations to the emergency department the re-presentation rate was 18.0% (n = 11,559) of visits and 14.4% (5,894/40,942) of all patients. Median time to re-presentation was 6 days, with more than half occurring within one week of discharge (60.8%; n = 6,873), and more than three-quarters within two weeks (80.9%; n = 9,151). The odds of re-presentation increased three-fold for people who were homeless compared to those living in stable accommodation (adjusted OR 3.09; 95% CI, 2.83 to 3.36). Similarly, the odds of re-presentation were significantly higher for patients receiving a government pension compared to those who did not (adjusted OR 1.73; 95% CI, 1.63 to 1.84), patients who left part-way through treatment compared to those who completed treatment and were discharged home (adjusted OR 1.64; 95% CI, 1.36 to 1.99), and those discharged to a residential-care facility compared to those who were discharged home (adjusted OR 1.46: 95% CI, 1.03 to 2.06). CONCLUSION: Emergency department re-presentation rates cluster around one week after discharge and rapidly decrease thereafter. Housing status and being a recipient of a government pension are the most significant risk factors. Early identification and appropriate referrals for those patients who are at risk of emergency department re-presentation will assist in the development of targeted strategies to improve health service delivery to this vulnerable group

Genomic analysis of atypical fibroxanthoma

Atypical fibroxanthoma (AFX), is a rare type of skin cancer affecting older individuals with sun damaged skin. Since there is limited genomic information about AFX, our study seeks to improve the understanding of AFX through whole-exome and RNA sequencing of 8 matched tumor-normal samples. AFX is a highly mutated malignancy with recurrent mutations in a number of genes, including COL11A1, ERBB4, CSMD3, and FAT1. The majority of mutations identified were UV signature (C>T in dipyrimidines). We observed deletion of chromosomal segments on chr9p and chr13q, including tumor suppressor genes such as KANK1 and CDKN2A, but no gene fusions were found. Gene expression profiling revealed several biological pathways that are upregulated in AFX, including tumor associated macrophage response, GPCR signaling, and epithelial to mesenchymal transition (EMT). To further investigate the presence of EMT in AFX, we conducted a gene expression meta-analysis that incorporated RNA-seq data from dermal fibroblasts and keratinocytes. Ours is the first study to employ high throughput sequencing for molecular profiling of AFX. These data provide valuable insights to inform models of carcinogenesis and additional research towards tumor-directed therapy

Pan-cancer analysis of whole genomes

Cancer is driven by genetic change, and the advent of massively parallel sequencing has enabled systematic documentation of this variation at the whole-genome scale(1-3). Here we report the integrative analysis of 2,658 whole-cancer genomes and their matching normal tissues across 38 tumour types from the Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium of the International Cancer Genome Consortium (ICGC) and The Cancer Genome Atlas (TCGA). We describe the generation of the PCAWG resource, facilitated by international data sharing using compute clouds. On average, cancer genomes contained 4-5 driver mutations when combining coding and non-coding genomic elements; however, in around 5% of cases no drivers were identified, suggesting that cancer driver discovery is not yet complete. Chromothripsis, in which many clustered structural variants arise in a single catastrophic event, is frequently an early event in tumour evolution; in acral melanoma, for example, these events precede most somatic point mutations and affect several cancer-associated genes simultaneously. Cancers with abnormal telomere maintenance often originate from tissues with low replicative activity and show several mechanisms of preventing telomere attrition to critical levels. Common and rare germline variants affect patterns of somatic mutation, including point mutations, structural variants and somatic retrotransposition. A collection of papers from the PCAWG Consortium describes non-coding mutations that drive cancer beyond those in the TERT promoter(4); identifies new signatures of mutational processes that cause base substitutions, small insertions and deletions and structural variation(5,6); analyses timings and patterns of tumour evolution(7); describes the diverse transcriptional consequences of somatic mutation on splicing, expression levels, fusion genes and promoter activity(8,9); and evaluates a range of more-specialized features of cancer genomes(8,10-18).Peer reviewe

Overlapping pK a of the Multiprotic Hemostyptic Eltrombopag using UV–Vis Multiwavelength Spectroscopy and Potentiometry

pH-potentiometric and WApH-spectrophotometric titrations of the multiprotic hemostyptic Eltrombopag for dissociation constants determination were compared. Hemostyptic and hemostatic Eltrombopag treats low blood platelet counts in adults with chronic immune idiopathic thrombocytopenia ITP. Eltrombopag exhibits five protonatable sites in a pH range of 2 to 10, where only two pK are well separated (ΔpK > 3), while the other three are near dissociation constants of overlapping equilibria. According to MARVIN prediction, in the neutral medium Eltrombopag occurs in the slightly water soluble form LH3 that can be protonated to the soluble species LH4 and LH5 The molecule LH3 can be dissociated to still difficultly soluble species LH2, LH and L. Due to limited solubility of Eltrombopag above pH 9.5 the protonation was studied up to pH 10. Five dissociation constants can be reliably determined with REACTLAB and SQUAD84 leading to the same value. From a dependence on ionic strength the thermodynamic dissociation constants were estimated at 25°C: pKa1T = 2.69, pKa2T = 6.97, pKa3T = 7.13, pKa4T = 7.65, pKa5T = 8.30. Since pH above 10 and pH down 5 occurs in a titrated solution the very fine precipitate of Eltrombopag which is initially forming a slight opalescence, this part of the potentiometric titration curve pH over 9 and pH below 5 was not taken into regression analysis to estimate pKa2 = 6.53(01), pKa3 = 7.60(04), pKa4 = 9.62(59), pKa5 = 10.55(340) at 25°C with ESAB and HYPERQUAD.Byly porovnávány potenciometrické hodnoty pH a WApH spektrofotometrické titrace multiprotického hemostyptického Eltrombopagu pro stanovení disociačních konstant. Hemostyptický a hemostatický Eltrombopag léčí nízké počty krevních destiček u dospělých pacientů s chronickou imunitní idiopatickou trombocytopenií ITP. Eltrombopag vykazuje pět protonovatelných míst v rozmezí pH od 2 do 10, kde jsou jen dva pK dobře oddělené (ΔpK> 3), zatímco ostatní tři jsou téměř disociační konstanty překrývající se rovnováhy. Podle predikce společnosti MARVIN se v neutrálním prostředí Eltrombopag vyskytuje ve formě lehce rozpustné ve vodě LH3, která může být protonována na rozpustné druhy LH4 a LH5. Molekula LH3 může být disociována na stále obtížně rozpustné druhy LH2, LH a L. Vzhledem k omezenému rozpustnosti Eltrombopagu nad pH 9,5 byla zkoumána protonace až na pH 10. Pět disociačních konstant může být spolehlivě stanoveno pomocí REACTLAB a SQUAD84, což vede k stejné hodnotě. Ze závislosti na iontové síle byly termodynamické disociační konstanty odhadnuty na 25 ° C: pKa1T = 2,69, pKa2T = 6,97, pKa3T = 7,13, pKa4T = 7,65, pKa5T = 8,30. Vzhledem k tomu, že pH v hodnotě nad 10 a pH 5 se vyskytuje v titrovaném roztoku, velmi jemná sraženina Eltrombopagu, která zpočátku vytváří mírnou opalescenci, tato část potenciometrické titrační křivky pH nad 9 a pH pod 5 nebyla převzata do regresní analýzy k odhadu pKa2 = 6,53 (01), pKa3 = 7,60 (04), pKa4 = 9,62 (59), pKa5 = 10,55 (340) při 25 ° C pomocí ESAB a HYPERQUAD

PTCH mutations in basal cell carcinomas from azathioprine-treated organ transplant recipients

The immunosuppressant azathioprine is used to prevent graft rejection after organ transplantation. To investigate whether azathioprine-associated mutagenesis contributes to the high incidence of skin tumours in organ transplant recipients (OTRs), we analysed PTCH gene mutations in 60 basal cell carcinomas (BCC); 39 from OTRs receiving azathioprine and 21 from individuals never exposed to azathioprine. PTCH was mutated in 55% of all tumours, independent of azathioprine treatment. In both the azathioprine and non-azathioprine groups, transitions at dipyrimidine sequences, considered to indicate mutation by ultraviolet-B radiation, occurred frequently in tumours from chronically sun-exposed skin. In BCC from non-sun-exposed skin of azathioprine-treated patients, there was an over-representation of unusual G:C to A:T transitions at non-dipyrimidine sites. These were exclusive to the azathioprine-exposed group and all in the same TGTC sequence context at different positions within PTCH. Meta-analysis of 247 BCCs from published studies indicated that these mutations are rare in sporadic BCC and had never previously been reported in this specific sequence context. This study of post-transplant BCC provides the first indication that azathioprine exposure may be associated with PTCH mutations, particularly in tumours from non-sun-exposed skin