The Effects of Patient Characteristics on the Management of Subclinical Hypothyroidism: A Survey of Faculty and Trainees.

OBJECTIVE: There is no universal approach to the management of subclinical hypothyroidism (SCH). This study was designed to determine the impact of patient characteristics on management decisions in SCH amongst physician faculty members and trainees. METHODS: An online survey was distributed to faculty members and medical trainees (ie, interns, residents, and fellows) at multiple academic medical centers. The survey included 9 clinical scenarios describing women with SCH with 5 management options sequenced from most "conservative" (no further treatment or monitoring) to most "aggressive" (treatment with levothyroxine). RESULTS: Of the 194 survey respondents, 95 (49.0%) were faculty members and 99 (51.0%) were trainees. Faculty members were more likely to report being "confident" or "very confident" in making the diagnosis of SCH compared to trainees (95.8% vs 46.5%, P < .001). Faculty members were also more likely to consider patient preference for treatment (60.0% vs 32.3%, P < .001). Among all respondents, the clinical factors that resulted in the highest predicted probability of treatment were hypothyroid symptoms (predicted probability [PP] 68.8%, 95% CI [65.7%-71.9%]), thyroid stimulating hormone >10 mIU/L in a 31-year-old (PP 63.9%, 95% CI [60.3%-67.3%]), and the desire for fertility (PP 52.2%, 95% CI [48.6%-56.0%]). In general, faculty members favored more aggressive treatment across all clinical scenarios. CONCLUSION: The presence of symptoms, thyroid stimulating hormone >10 mIU/L, and desire for fertility were most predictive of the decision to treat in SCH. In several clinical scenarios, both trainee and faculty decision-making demonstrated discordance with general SCH management principles.

Using Online Simulation of Pediatric Musculoskeletal Cases to Evaluate How Knowledge of Costs Affects Diagnostic Workup.

BACKGROUND: Rising healthcare costs have emphasized the need to teach cost-conscious care in graduate medical education. OBJECTIVE: To teach high-value care and diagnostic evaluation of pediatric musculoskeletal complaints to residents and rotating medical students through online cases. METHODS: Six online cases were developed and tested at the University Hospitals Cleveland Medical Center. Learners completed modules in one of two groups, those who saw itemized costs of diagnostic tests or those who did not. All learners completed a post-simulation survey. Measured outcomes included presumed diagnosis, cost of evaluation, tests ordered, and perceptions toward high-value care. Simulation outcomes were assessed using paired t-tests. Survey data was analyzed with Chi-squared tests. Outcomes separated by training year were analyzed using ANOVA and post-hoc Tukey test. RESULTS: Thirty-nine residents and medical students participated and were randomly assigned to complete the cases with costs (n = 19) or no costs (n = 20) displayed during workup. Overall, learners who saw costs spent less money on diagnostics ($1511.11 mean per learner versus $2311.35, p = 0.01). Arrival at the correct diagnosis was associated with lower costs in 3 of 6 cases. When compared to the no cost group, learners in the costs group reported feeling more knowledgeable about the price of diagnostic tests (p = 0.04) and were more likely to factor costs into their practice moving forward (p = 0.03). Third year or above residents demonstrated a statically significant increase in correctly diagnosed cases as opposed to medical students. CONCLUSIONS: Interventions that challenge learners to integrate costs into decision-making can potentially change future practice.

The targeted delivery of doxorubicin with transferrin-conjugated block copolypeptide vesicles.

We previously investigated the intracellular trafficking properties of our novel poly(l-glutamate)60-b-poly(l-leucine)20 (E60L20) vesicles (EL vesicles) conjugated to transferrin (Tf). In this study, we expand upon our previous work by investigating the drug encapsulation, release, and efficacy properties of our novel EL vesicles for the first time. After polyethylene glycol (PEG) was conjugated to the vesicles for steric stability, doxorubicin (DOX) was successfully encapsulated in the vesicles using a modified pH-ammonium sulfate gradient method. Tf was subsequently conjugated to the vesicles to provide active targeting to cancer cells and a mode of internalization into the cells. These Tf-conjugated, DOX-loaded, PEGylated EL (Tf-DPEL) vesicles exhibited colloidal stability and were within the allowable size range for passive and active targeting. A mathematical model was then derived to predict drug release from the Tf-DPEL vesicles by considering diffusive and convective mass transfer of DOX. Our mathematical model reasonably predicted our experimentally measured release profile with no fitted parameters, suggesting that the model could be used in the future to manipulate drug carrier properties to alter drug release profiles. Finally, an in vitro cytotoxicity assay was used to demonstrate that the Tf-DPEL vesicles exhibited enhanced drug carrier efficacy in comparison to its non-targeted counterpart.

Modeling mass transfer from carmustine-loaded polymeric implants for malignant gliomas.

Significant advances in the encapsulation and release of drugs from degradable polymers have led to the Food and Drug Administration approval of Gliadel wafers for controlled local delivery of the chemotherapeutic drug carmustine to high-grade gliomas following surgical resection. Due to the localized nature of the delivery method, no pharmacokinetic measurements have been taken in humans. Rather, pharmacokinetic studies in animals and associated modeling have indicated the capability of carmustine to be delivered in high concentrations within millimeters from the implant site over approximately 5 days. Mathematical models have indicated that diffusion has a primary role in transport, which may be complemented by enhanced fluid convection from postsurgical edema in the initial 3 days following implantation. Carmustine's penetration distance is also presumably limited by its lipophilicity and permeability in the capillaries. This review discusses the mathematical models that have been used to predict the release and distribution of carmustine from a polymeric implant. These models provide a theoretical framework for greater understanding of systems for localized drug delivery while highlighting factors that should be considered in clinical applications. In effect, Gliadel wafers and similar drug delivery implants can be optimized with reduction in required time and resources with such a quantitative and integrative approach.

Simultaneous concentration and detection of biomarkers on paper.

The lateral-flow immunoassay (LFA) is an inexpensive point-of-care (POC) paper-based diagnostic device with the potential to rapidly detect disease biomarkers in resource-poor settings. Although LFA is inexpensive, easy to use, and requires no laboratory equipment, it is limited by its sensitivity, which remains inferior to that of gold standard laboratory-based assays. Our group is the only one to have previously utilized various aqueous two-phase systems (ATPSs) to enhance LFA detection. In those studies, the sample was concentrated by an ATPS in a test tube and could only be applied to LFA after it had been extracted manually. Here, we bypass the extraction step by seamlessly integrating a polyethylene glycol-potassium phosphate ATPS with downstream LFA detection in a simple, inexpensive, power-free, and portable all-in-one diagnostic device. We discovered a new phenomenon in which the target biomarkers simultaneously concentrate as the ATPS solution flows through the paper membranes, and our device features a 3-D paper well that was designed to exploit this phenomenon. Studies with this device, which were performed at room temperature in under 25 min, demonstrated a 10-fold improvement in the detection limit of a model protein, transferrin. Our next-generation LFA technology is rapid, affordable, easy-to-use, and can be applied to existing LFA products, thereby providing a new platform for revolutionizing the current state of disease diagnosis in resource-poor settings.