Cost-effectiveness Analysis of Feeding Guidelines for Infants Following Intestinal Surgery.

OBJECTIVE: The aim of the study was to determine the cost-effectiveness of postoperative feeding guidelines to reduce complications in infants with intestinal surgery compared to standard feeding practices. METHODS: Using outcomes from a cohort study, Markov models from health care and societal perspectives simulated costs per hospitalization among infants fed via guidelines versus standard practice. Short-term outcomes included intestinal failure-associated liver disease, necrotizing enterocolitis after feeding, sepsis, and mortality. Effectiveness was measured as length of stay. The incremental cost-effectiveness ratios (ICER) compared cost over length of stay. Univariate and multivariate probabilistic sensitivity analyses with 10,000 Monte Carlo Simulations were performed. A second decision tree model captured the cost per quality-adjusted life years (QALYs) using utilities associated with long-term outcomes (liver cirrhosis and transplantation). RESULTS: In the hospital perspective, standard feeding had a cost of $31,258,902 and 8296 hospital days, and the feeding guidelines had a cost of $29,295,553 and 8096 hospital days. The ICER was $-9832 per hospital stay with guideline use. More than 90% of the ICERs were in the dominant quadrant. Results were similar for the societal perspective. Long-term costs and utilities in the guideline group were $2830 and 0.91, respectively, versus $4030 and 0.90, resulting in an ICER of $-91,756/QALY. CONCLUSION: In our models, feeding guideline use resulted in cost savings and reduction in hospital stay in the short-term and cost savings and an increase in QALYs in the long-term. Using a systematic approach to feed surgical infants appears to reduce costly complications, but further data from a larger cohort are needed.

Ancient DNA from a 2,500-year-old Caribbean fossil places an extinct bird (Caracara creightoni) in a phylogenetic context.

Since the late Pleistocene humans have caused the extinction of species across our planet. Placing these extinct species in the tree of life with genetic data is essential to understanding the ecological and evolutionary implications of these losses. While ancient DNA (aDNA) techniques have advanced rapidly in recent decades, aDNA from tropical species, especially birds, has been historically difficult to obtain, leaving a gap in our knowledge of the extinction processes that have influenced current distributions and biodiversity. Here we report the recovery of a nearly complete mitochondrial genome from a 2,500 year old (late Holocene) bone of an extinct species of bird, Caracara creightoni, recovered from the anoxic saltwater environment of a blue hole in the Bahamas. Our results suggest that this extinct species is sister (1.6% sequence divergence) to a clade containing the extant C. cheriway and C. plancus. Caracara creightoni shared a common ancestor with these extant species during the Pleistocene (1.2-0.4 MYA) and presumably survived on Cuba when the Bahamas was mostly underwater during Quaternary interglacial intervals (periods of high sea levels). Tropical blue holes have been collecting animals for thousands of years and will continue to improve our understanding of faunal extinctions and distributions. In particular, new aDNA techniques combined with radiocarbon dating from Holocene Bahamian fossils will allow us to place other extinct (species-level loss) and extirpated (population-level loss) vertebrate taxa in improved phylogenetic, evolutionary, biogeographic, and temporal contexts.

An evaluation of longitudinal changes in serum uric acid levels and associated risk of cardio-metabolic events and renal function decline in gout.

OBJECTIVE: Gout patients have a high burden of co-morbid conditions including diabetes mellitus (DM), chronic kidney disease (CKD), and cardiovascular disease (CVD). We sought to evaluate the association between changes in serum uric acid (SUA) levels over time and the risk of incident DM, CVD, and renal function decline in gout patients. METHODS: An observational cohort study was conducted among enrollees of private health insurance programs in the US between 2004 and 2015. Gout patients were included on the index date of a SUA measurement ≥6.8 mg/dl. The exposure of interest was cumulative change in SUA levels from baseline. Hazard ratios (HR) and 95% confidence intervals (CI) for incident DM, incident CVD, and renal function decline (≥30% reduction in glomerular filtration rate) were derived using marginal structural models with stabilized inverse probability weights accounting for baseline confounders (age, gender, co-morbidities, co-medications) and time-varying confounders (serum creatinine, blood urea nitrogen, glycated hemoglobin). RESULTS: Among 26,341 patients with gout, the average age was 62, 75% were men, and the median baseline SUA was 8.6 mg/dl (interquartile range 7.7 to 9.5). The incidence rates/100 person-years (95% CI) were 1.63 (1.51-1.75) for DM, 0.77 (0.70-0.84) for CVD, and 4.32 (4.14-4.49) for renal function decline. The adjusted HR (95% CI) per 3 mg/dl reduction in SUA, corresponding on average to achieving the target level of <6 mg/dl in this population, was 1.04 (0.92-1.17) for DM, 1.07 (0.89-1.29) for CVD, and 0.85 (0.78-0.92) for renal function decline. CONCLUSIONS: Reduction in SUA in patients with gout may be associated with a reduced risk of renal function decline, but not with DM or CVD.

Tropylium ion mediated α-cyanation of amines.

Tropylium ion mediated α-cyanation of amines is described. Even in the presence of KCN, tropylium ion is capable of oxidizing various amine substrates, and the resulting iminium ions undergo salt metathesis with cyanide ion to produce aminonitriles. The byproducts of this transformation are simply cycloheptatriene, a volatile hydrocarbon, and water-soluble potassium tetrafluoroborate. Thirteen total substrates are shown for the α-cyanation procedure, including a gram scale synthesis of 17ß-cyanosparteine. In addition, a tropylium ion mediated oxidative aza-Cope rearrangement is demonstrated.

Multicatalytic synthesis of complex tetrahydrofurans involving bismuth(III) triflate catalyzed intramolecular hydroalkoxylation of unactivated olefins.

A multicatalytic synthesis of complex tetrahydrofurans has been developed involving a Bi(OTf)(3)-catalyzed nucleophilic addition/hydroalkoxylation sequence. Complex tetrahydrofuranyl products may be formed rapidly in high yield and with good diastereoselectivity. The demonstrated scope of hydroalkoxylation has also been expanded to include substrates bearing useful functional handles including carboxylate ester, olefin, nitrile, and nitro groups.

Why are a(3) ions rarely observed?

It has been determined experimentally that a(3) ions are generally not observed in the tandem mass spectroscopic (MS/MS) spectra of b(3) ions. This is in contrast to other b(n) ions, which often have the corresponding a(n) ion as the base peak in their MS/MS spectra. Although this might suggest a different structure for b(3) ions compared to that of other b(n) ions, theoretical calculations indicate the conventional oxazolone structure to be the lowest energy structure for the b(3) ion of AAAAR, as it is for other b(n) ions of this peptide. However, it has been determined theoretically that the a(3) ion is lower in energy than other a(n) ions, relative to the corresponding b ions. Furthermore, the a(3) --> b(2) transition structure (TS) is lower in energy than other a(n) --> b(n-1) TSs of AAAAR, compared with the corresponding b ions. Consequently, it is suggested that the b(3) ion does fragment to the a(3) ion, but that the a(3) ion then immediately fragments (to b(2) and a(3)) because of the excess internal energy arising from its relatively low energy and the facile a(3) --> b(2) reaction. That is why a(3) ions are not observed in the MS/MS spectra of b(3) ions.

Heroin-induced locomotor activity and conditioned place preference in C57BL/6J and 129P3/J mice.

Differences in the locomotor stimulating and rewarding properties of drugs of abuse have been described in several inbred strains of mice, and comparisons of inbred strains with differing responses to drugs of abuse may provide crucial insight into the question of individual vulnerability to the effects of drugs of abuse. The present study was designed to examine the rewarding and locomotor-stimulating effects of heroin in C57BL/6J and 129P3/J mice. Heroin produced a robust dose-dependent locomotor stimulation in both strains. Both strains also developed conditioned place preference to heroin, again in a dose-dependent manner. However C57BL/6J mice developed conditioned place preference to only the two lowest doses of heroin tested, while the 129P3/J counterparts showed conditioned place preference to only the three highest doses tested. These studies indicate that 129P3/J mice are less sensitive to the rewarding effects of heroin than are age-matched C57BL/6J mice.

Effects of gender and cigarette smoking on reactivity to psychological and pharmacological stress provocation.

We examined the influence of gender and smoking status on reactivity in two human laboratory stress paradigms. Participants were 46 (21 men, 25 women) healthy individuals who completed the Trier Social Stress Task (i.e., performed speech and math calculations in front of an audience) and a pharmacological stress provocation (i.e., administration of corticotrophin releasing hormone (CRH)) after an overnight hospital stay. Approximately half (53%) of the participants were smokers. Cortisol, adrenocorticotrophin hormone (ACTH), physiologic measures (heart rate, blood pressure), and subjective stress were assessed at baseline and at several time points post-task. Men demonstrated higher baseline ACTH and blood pressure as compared to women; however, ACTH and blood pressure responses were more pronounced in women. Women smokers evidenced a more blunted cortisol response as compared to non-smoking women, whereas smoking status did not affect the cortisol response in men. Finally, there was a more robust cardiovascular and subjective response to the Trier as compared to the CRH. Although preliminary, the findings suggest that women may be more sensitive than men to the impact of cigarette smoking on cortisol response. In addition, there is some evidence for a more robust neuroendocrine and physiologic response to acute laboratory stress in women as compared to men.

Use of infliximab-daclizumab combination for the treatment of acute and chronic graft-versus-host disease of the liver and gut.

Infliximab-daclizumab was used to treat acute and chronic liver and gut graft-versus-host disease (GVHD) in two children after standard immunosuppressive therapy failed. Infliximab (10 mg/kg weekly, 4 doses) and daclizumab (1 mg/kg, days 1, 4, 8, 15, and 22) were given over 1 month. In case 1, grade 2 chronic GVHD of the liver developed 1 year after transplantation and failed to improve with tacrolimus, mycophenolate mofetil, and prednisone. In case 2, corticosteroid-unresponsive grade 3 acute liver and gut GVHD developed on day +37. In both patients, GVHD responded to the infliximab-daclizumab regimen without toxicity and immunosuppressive therapy was discontinued.