Limit Theorems for Individual-Based Models in Economics and Finance

There is a widespread recent interest in using ideas from statistical physics to model certain types of problems in economics and finance. The main idea is to derive the macroscopic behavior of the market from the random local interactions between agents. Our purpose is to present a general framework that encompasses a broad range of models, by proving a law of large numbers and a central limit theorem for certain interacting particle systems with very general state spaces. To do this we draw inspiration from some work done in mathematical ecology and mathematical physics. The first result is proved for the system seen as a measure-valued process, while to prove the second one we will need to introduce a chain of embeddings of some abstract Banach and Hilbert spaces of test functions and prove that the fluctuations converge to the solution of a certain generalized Gaussian stochastic differential equation taking values in the dual of one of these spaces.Comment: To appear in Stochastic Processes and their Application

A Unique Researcher Identifier for the Physician Payments Sunshine Act

The Physician Payments Sunshine Act (PPSA) promises a new era of transparency for the US health care system. Signed into law on March 23, 2010, the PPSA is part of the Patient Protection and Affordable Care Act of 2009.1 The PPSA requires medical product companies to report to the Department of Health and Human Services (DHHS) a range of “transfers of value” to covered recipients (physicians and teaching hospitals). With some exceptions, these transfers and their value will be publicly disclosed.Governmen

Evaluating the Effect of Telestroke Intervention on Patient Treatment and Outcomes

Acute ischemic strokes (AIS) are a prominent cause of death and have the potential to cause lifelong neurological deficits. We hypothesize that through telestroke intervention, patients will receive treatment more rapidly and therefore have reduced complications as a result of AIS. To analyze the efficacy of telestroke intervention, we completed a retrospective chart review of suspected AIS patients at hospitals in the greater Philadelphia region from 2015-2019. We then assessed whether a patient received a telestroke consultation and any subsequent care. Several variables were then used to determine the effectiveness of this intervention, such as the promptness of treatment, length of stay in the hospital, and the need for surgical intervention. The total study cohort included 9072 patients, with 811 (8.9%) patients fulfilling the criteria to receive tPA therapy. For patients with a known time of onset, the average amount of time to receive a consultation was 227 minutes, within the 4.5-hour time frame needed for tPA administration. Furthermore, a total of 195 (2.1%) patients experienced a major complication and 155 (1.7%) patients expired despite receiving telestroke intervention. This large cohort is further evidence that quicker access to neurological consultation results in more prompt treatment and an increase in positive patient outcomes. Additionally, we expect this study will push the medical field towards more widespread use of telemedicine; an especially relevant topic as medicine becomes more reliant on technology in the face of potential public health crises

Evaluating the Efficacy of Telestroke Intervention in a Large Community Hospital Network

Introduction: Telemedicine for acute ischemic stroke (Telestroke) allows live consultation between patients, remote stroke specialists, and providers to facilitate administration of IV tissue plasminogen activator (IV-tPA) within the 4.5 hour window. Small cohort studies have demonstrated thrombolytic therapy conveys significant benefit to stroke outcomes and yet is underutilized due to difficulties in recognition and delivery of medication. This study proposes that access to telestroke care across the Thomas Jefferson University Hospital network will result in increased thrombolytic reperfusion rates and improved patient outcomes for stroke. Methods: A retrospective cohort study was designed to utilize a telestroke database collecting information from 9,702 patients evaluated through telestroke across the Jefferson network of 36 community hospitals from 2014-2019. The rate of tPA administration and NIHSS stroke scores were collected. These rates were compared to values in the literature that represent current standard of care without telestroke. Results: Analysis is not complete due to difficulties with the size of the dataset. Preliminary analysis reveals that 807 of the 9,702 patients (8.3%) evaluated for stroke received tPA compared to a national rate of 3.4-5.2% in stroke patients. Furthermore, tPA administration resulted in a significant improvement in NIHSS stroke scale (p\u3c0.0001; 95% confidence interval [CI] = 4.27, 7.80). Discussion: The results support the hypothesis that tPA is administered effectively though a telestroke system. The greater rate of administration across a large cohort implies significantly improved outcomes for patients on a large scale. The study supports the implementation of large telestroke systems similar to Jefferson’s for improved care

Evaluating the Efficacy of Telestroke Intervention on Stroke Care in a Large Hospital Network

Introduction: Telestroke medicine (TM) involves clinical stroke care by digitally connecting patients and their providers to neurovascular specialists to decrease the time to thrombolytic reperfusion during an acute ischemic stroke (AIS). Rapid administration of intravenous tissue plasminogen activator (iv-tPA) improves AIS outcomes yet no large scale research has evaluated the effectiveness of TM. This study proposes that TM utilization across the Jefferson University Hospital network will increase thrombolytic reperfusion rates and improve overall stroke outcomes. Methods: A retrospective cohort study design with data from a Jefferson Telestroke database contained information for 9,702 patients across 36 hospital affiliates. These patients were evaluated for an AIS through Telestroke from 2014-2019. The rate of iv-tPA administration and NIHSS stroke severity scores were collected. This data was then compared to previous studies that represent the current standard of care without Telestroke through utilization of T-test and ANOVA analysis. Results: An analysis is currently in progress. Preliminary analysis demonstrated that 807 out of 9,702 patients (8.3%) evaluated for AIS received iv-tPA when compared to a national average of 3.4%-5.2%. Additionally, a statistically significant improvement in NIHSS score from baseline to after administration of iv-tPA (p\u3c0.0001; 95% confidence interval [CI] = 4.27, 7.80) was found in this cohort. Discussion: The results of this study support the hypothesis that TM increases the rate of administration of iv-tPA when compared to the national average and improves AIS outcomes. The study describes the effectiveness of TM and demonstrates a need for implementation of Telestroke nationally to improve stroke care

Age-related biological features of germ cell tumors.

Germ cell tumors (GCTs) are rare but clinically and pathologically diverse tumors that occur in an extensive range of age groups, from children to older adults and which include both seminomatous and nonseminomatous tumors. Current clinical management for both male and female teenagers and young adults (TYAs) with GCTs remains inconsistent, alternating between pediatric and adult multidisciplinary oncology teams, based on locally defined age cutoffs. Therefore, we reviewed available literature to determine the biological similarities and differences between GCTs in young children (0-12 years), TYAs (13-24 years), and older adults (>24 years). GCTs arising in pediatric and adult populations in general showed marked molecular biological differences within identical histological subtypes, whereas there was a distinct paucity of available data for GCTs in the TYA population. These findings highlight that clinical management based simply on chronological age may be inappropriate for TYA and suggests that the optimal future management of GCTs should consider specific molecular biological factors in addition to clinical parameters in the context of patient-specific age group rather than medical specialty.This is the accepted manuscript. The final version is available at http://onlinelibrary.wiley.com/doi/10.1002/gcc.22131/abstract

Incidence of cutaneous melanoma and Merkel cell carcinoma in patients with primary cutaneous B-cell lymphomas: A population study of the SEER registry

IntroductionThe increased incidence of cutaneous melanoma (CM) and Merkel cell carcinoma (MCC) in patients with hematologic malignancies (HM) is well established. While the risk of CM has been assessed in some subtypes of HM including cutaneous T-cell lymphoma, the incidence in patients with primary cutaneous B-cell lymphoma (PCBCL) has not been interrogated.MethodsHere we evaluated the standardized incidence ratio (SIR) of CM and MCC in 5,179 PCBCL patients compared to approximately 1.5 billion individuals in the general population using the Surveillance, Epidemiology and End Results (SEER) database. Among patients with PCBCL, we identified subgroups that were at increased risk for CM or MCC as a second primary cancer.ResultsWe found 36 cases of CM in the PCBCL cohort (SIR, 1.35; 95% CI, 0.94–1.86), among which SIR was significantly elevated for non-Hispanic White patients compared to the general population (SIR, 1.48; 95% CI, 1.03–2.06). Males had a significantly increased risk of developing CM after a diagnosis of PCBCL (SIR, 1.60; 95% CI, 1.10–2.26). We found that males in the age group of 50–59 were at increased risk for CM development (SIR, 3.02; 95% CI, 1.11–6.58). Males were at increased risk of CM 1–5 years after PCBCL diagnosis (SIR, 2.06; 95% CI, 1.18–3.34). Patients were at greater risk of developing MCC within 1 year of diagnosis of PCBCL (SIR, 23.60; 95% CI, 2.86–85.27), particularly in patients who were over the age of 80 (SIR, 46.50; 95% CI, 5.63–167.96). Males aged 60–69 with PCBCL, subtype marginal zone, were also at increased risk for MCC (SIR, 42.71; 95% CI, 1.08–237.99).ConclusionThere is an increased incidence of CM in White, middle-aged males within 5 years of diagnosis of PCBCL and an increased risk of MCC in elderly patients within 1 year of PCBCL diagnosis. These data suggest that certain subgroups of patients with PCBCL may require more rigid surveillance for CM and MCC

Incidence of Cutaneous Melanoma and Merkel Cell Carcinoma in Patients With Primary Cutaneous B-Cell Lymphomas: A Population Study of the SEER Registry

Introduction: The increased incidence of cutaneous melanoma (CM) and Merkel cell carcinoma (MCC) in patients with hematologic malignancies (HM) is well established. While the risk of CM has been assessed in some subtypes of HM including cutaneous T-cell lymphoma, the incidence in patients with primary cutaneous B-cell lymphoma (PCBCL) has not been interrogated. Methods: Here we evaluated the standardized incidence ratio (SIR) of CM and MCC in 5,179 PCBCL patients compared to approximately 1.5 billion individuals in the general population using the Surveillance, Epidemiology and End Results (SEER) database. Among patients with PCBCL, we identified subgroups that were at increased risk for CM or MCC as a second primary cancer. Results: We found 36 cases of CM in the PCBCL cohort (SIR, 1.35; 95% CI, 0.94–1.86), among which SIR was significantly elevated for non-Hispanic White patients compared to the general population (SIR, 1.48; 95% CI, 1.03–2.06). Males had a significantly increased risk of developing CM after a diagnosis of PCBCL (SIR, 1.60; 95% CI, 1.10–2.26). We found that males in the age group of 50–59 were at increased risk for CM development (SIR, 3.02; 95% CI, 1.11–6.58). Males were at increased risk of CM 1–5 years after PCBCL diagnosis (SIR, 2.06; 95% CI, 1.18–3.34). Patients were at greater risk of developing MCC within 1 year of diagnosis of PCBCL (SIR, 23.60; 95% CI, 2.86–85.27), particularly in patients who were over the age of 80 (SIR, 46.50; 95% CI, 5.63–167.96). Males aged 60–69 with PCBCL, subtype marginal zone, were also at increased risk for MCC (SIR, 42.71; 95% CI, 1.08–237.99). Conclusion: There is an increased incidence of CM in White, middle-aged males within 5 years of diagnosis of PCBCL and an increased risk of MCC in elderly patients within 1 year of PCBCL diagnosis. These data suggest that certain subgroups of patients with PCBCL may require more rigid surveillance for CM and MCC

Immunosequencing Applications in Cutaneous T-Cell Lymphoma

Immunosequencing has emerged as a newer clinical test for assessment of T-cell clonality in the blood and skin of cutaneous T-cell lymphoma (CTCL) patients. Utilization of immunosequencing, also known as high-throughput sequencing of the T-cell receptor (HTS-TCR), enables identification and quantification of the precise genetic signature of dominant T-cell clones. Although immunosequencing is more sensitive than commonly used methods such as polymerase chain reaction (PCR) paired with capillary electrophoresis or flow cytometry, it remains underutilized for CTCL management. Nonetheless, incorporation of HTS-TCR in clinical practice offers distinct advantages compared to other molecular analyses that may improve diagnostic evaluation, prognostication, and disease monitoring in CTCL. The objective of this comprehensive review is to provide a thorough explanation of the application of immunosequencing in the context of CTCL. We describe the significance of T-cell clonality and the methods used to detect it, including a detailed comparison between PCR paired with capillary electrophoresis and HTS-TCR. The utilization of immunosequencing in the blood and skin of CTCL patients is discussed in depth, specifically outlining how HTS-TCR can assist in diagnosing CTCL, predicting outcomes, and tracking disease progression. Finally, we address the potential applications of immunosequencing in clinical management and research as well as the novel challenges it presents

Accelerated BEP : a phase I trial of dose-dense BEP for intermediate and poor prognosis metastatic germ cell tumour

Background: We used bleomycin, etoposide, cisplatin (BEP), the most effective regimen in the treatment of germ cell tumours (GCTs) and increased dose-density by using pegfilgrastim to shorten cycle length. Our aim was to assess safety and tolerability. Methods: Sixteen male patients with intermediate or poor prognosis metastatic GCT were treated with four cycles of 3-day BEP with G-CSF on a 14-day cycle for a planned relative dose-density of 1.5 compared with standard BEP. Results: Eleven intermediate and five poor prognosis patients were treated. In all, 14 of 16 patients completed the study treatment. Toxicities were comparable to previous studies using standard BEP, except for mucositis and haematological toxicity that were more severe. The overall relative dose-density for all 16 patients was mean 1.38 (range 0.72–1.5; median 1.46). Complete response was achieved after chemotherapy alone in two patients (13%) and following chemotherapy plus surgery in nine additional patients (56%). Four patients (25%) had a partial response and normalised their marker levels. At a median follow-up of 4.4 years (range 2.1–6.8) the estimated 5-year progression-free survival probability is 81% (95% CI 64–100%). Conclusion: Accelerated BEP is tolerable without major additional toxicity. A randomised controlled trial will be required to obtain comparative efficacy data