Costs and outcomes of noncardioembolic ischemic stroke in a managed care population

Nicole M Engel-Nitz1, Stephen D Sander2, Carolyn Harley3, Gabriel Gomez Rey1, Hemal Shah21Health Economic and Outcomes Research, i3 Innovus, Eden Prairie, MN, USA; 2Health Economic and Outcomes Research, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA; 3Health Economic and Outcomes Research, i3 Innovus, Palo Alto, CA, USAPurpose: To evaluate the clinical outcomes and incremental health care costs of ischemic stroke in a US managed care population.Patients and methods: A retrospective cohort analysis was done on patients (aged 18+ years) hospitalized with noncardioembolic ischemic stroke from January 1, 2002, through ­December 31, 2003, identified from commercial health plan administrative claims. New or recurrent stroke was based on history in the previous 12 months, with index date defined as first date of ­indication of stroke. A control group without stroke or transient ischemic attack (TIA) was matched (1:3) on age, sex, and geographic region, with an index date defined as the first ­medical claim during the patient identification period. Patients with atrial fibrillation or mitral value abnormalities were excluded. Ischemic stroke and control cohorts were compared on 4-year clinical outcomes and 1-year costs.Results: Of 2180 ischemic stroke patients, 1808 (82.9%) had new stroke and 372 (17.1%) had a recurrent stroke. Stroke patients had higher unadjusted rates of additional stroke, TIA, and fatal outcomes compared with the 6540 matched controls. Recurrent stroke patients had higher rates of adverse clinical outcomes compared with new stroke patients; costs attributed to recurrent stroke were also higher. Stroke patients were 2.4 times more likely to be hospitalized in follow-up compared with controls (hazard ratio [HR] 2.4, 95% confidence interval [CI]: 2.2, 2.6). Occurrence of stroke following discharge was 21 times more likely among patients with index stroke compared with controls (HR 21.0, 95% CI: 16.1, 27.3). Stroke was also predictive of death (HR 1.8, 95% CI: 1.3, 2.5). Controlling for covariates, stroke patients had significantly higher costs compared with control patients in the year following the index event.Conclusion: Noncardioembolic ischemic stroke patients had significantly poorer outcomes and higher costs compared with controls. Recurrent stroke appears to contribute substantially to these higher rates of adverse outcomes and costs.Keywords: burden of illness, stroke⁄cerebrovascular accident, cardiovascular disease, claims analysis, costs of care, health care outcome

Modified laminar bone in Ampelosaurus atacis and other titanosaurs (Sauropoda): Implications for life history and physiology

Background: Long bone histology of the most derived Sauropoda, the Titanosauria suggests that titanosaurian long bone histology differs from the uniform bone histology of basal Sauropoda. Here we describe the long bone histology of the titanosaur Ampelosaurus atacis and compare it to that of basal neosauropods and other titanosaurs to clarify if a special titanosaur bone histology exists. Methodology/Principal Findings: Ampelosaurus retains the laminar vascular organization of basal Sauropoda, but throughout most of cortical growth, the scaffolding of the fibrolamellar bone, which usually is laid down as matrix of woven bone, is laid down as parallel-fibered or lamellar bone matrix instead. The remodeling process by secondary osteons is very extensive and overruns the periosteal bone deposition before skeletal maturity is reached. Thus, no EFS is identifiable. Compared to the atypical bone histology of Ampelosaurus, the large titanosaur Alamosaurus shows typical laminar fibrolamellar bone. The titanosaurs Phuwiangosaurus, Lirainosaurus, and Magyarosaurus, although differing in certain features, all show this same low amount or absence of woven bone from the scaffolding of the fibrolamellar bone, indicating a clear reduction in growth rate resulting in a higher bone tissue organization. To describe the peculiar primary cortical bone tissue of Phuwiangosaurus, Ampelosaurus, Lirainosaurus, and Magyarosaurus, we here introduce a new term, "modified laminar bone" (MLB). Conclusions/Significance: Importantly, MLB is as yet not known from extant animals. At least in Lirainosaurus and Magyarosaurus the reduction of growth rate indicated by MLB is coupled with a drastic body size reduction and maybe also a reduction in metabolic rate, interpreted as a result of dwarfing on the European islands during the Late Cretaceous. Phuwiangosaurus and Ampelosaurus both show a similar reduction in growth rate but not in body size, possibly indicating also a reduced metabolic rate. The large titanosaur Alamosaurus, on the other hand, retained the plesiomorphic bone histology of basal neosauropods.Fil: Klein, Nicole. Universitat Bonn; AlemaniaFil: Sander, P. Martin. Universitat Bonn; AlemaniaFil: Stein, koen. Universitat Bonn; AlemaniaFil: Loeuff, L. Jean.. Musée Des Dinosaures; FranciaFil: Carballido, José Luis. Provincia del Chubut. Fundación Egidio Feruglio. Museo Paleontológico ; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Buffetaut, Éric. Centre National de la Recherche Scientifique; Franci

Heads or tails first? Evolution of fetal orientation in ichthyosaurs, with a scrutiny of the prevailing hypothesis

According to a longstanding paradigm, aquatic amniotes, including the Mesozoic marine reptile group Ichthyopterygia, give birth tail-first because head-first birth leads to increased asphyxiation risk of the fetus in the aquatic environment. Here, we draw upon published and original evidence to test two hypotheses: (1) Ichthyosaurs inherited viviparity from a terrestrial ancestor. (2) Asphyxiation risk is the main reason aquatic amniotes give birth tail-first. From the fossil evidence, we conclude that head-first birth is more prevalent in Ichthyopterygia than previously recognized and that a preference for tail-first birth likely arose in derived forms. This weakens the support for the terrestrial ancestry of viviparity in Ichthyopterygia. Our survey of extant viviparous amniotes indicates that fetal orientation at birth reflects a broad diversity of factors unrelated to aquatic vs. terrestrial habitat, further undermining the asphyxiation hypothesis. We propose that birth preference is based on parturitional mechanics or carrying efficiency rather than habitat

Near-Infrared Fluorescence Imaging for Real-Time Intraoperative Guidance in Anastomotic Colorectal Surgery:A Systematic Review of Literature

Purpose: The aims of this review are to determine the feasibility of near-infrared fluorescence (NIRF) angiography in anastomotic colorectal surgery and to determine the effectiveness of the technique in improving imaging and quantification of vascularization, thereby aiding in decision making as to where to establish the anastomosis. Methods: A systematic literature search of PubMed and EMBASE was conducted. Searching through the reference lists of selected articles identified additional studies. All English language articles presenting original patient data regarding intraoperative NIRF angiography were included without restriction of type of study, except for case reports, technical notes, and video vignettes. The intervention consisted of intraoperative NIRF angiography during anastomotic colorectal surgery to assess perfusion of the colon, sigmoid, and/or rectum. Primary outcome parameters included ease of use, added surgical time, complications related to the technique, and costs. Other relevant outcomes were whether this technique changed intraoperative decision making, whether effort was taken by the authors to quantify the signal and the incidence of postoperative complications. Results: Ten studies were included. Eight of these studies make a statement about the ease of use. In none of the studies complications due to the use of the technique occurred. The technique changed the resection margin in 10.8% of all NIRF cases. The anastomotic leak rate was 3.5% in the NIRF group and 7.4% in the group with conventional imaging. Two of the included studies used an objective quantification of the fluorescence signal and perfusion, using ROIs (Hamamatsu Photonics) and IC-Calc® respectively. Conclusions: Although the feasibility of the technique seems to be agreed on by all current research, large clinical trials are mandatory to further evaluate the added value of the technique

Approach to Estimate the Phase Formation and the Mechanical Properties of Alloys Processed by Laser Powder Bed Fusion via Casting

A high-performance tool steel with the nominal composition Fe85Cr4Mo8V2C1 (wt%) was processed by three different manufacturing techniques with rising cooling rates: conventional gravity casting, centrifugal casting and an additive manufacturing process, using laser powder bed fusion (LPBF). The resulting material of all processing routes reveals a microstructure, which is composed of martensite, austenite and carbides. However, comparing the size, the morphology and the weight fraction of the present phases, a significant difference of the gravity cast samples is evident, whereas the centrifugal cast material and the LPBF samples show certain commonalities leading finally to similar mechanical properties. This provides the opportunity to roughly estimate the mechanical properties of the material fabricated by LPBF. The major benefit arises from the required small material quantity and the low resources for the preparation of samples by centrifugal casting in comparison to the additive manufacturing process. Concluding, the present findings demonstrate the high attractiveness of centrifugal casting for the effective material screening and hence development of novel alloys adapted to LPBF-processing

Testing the Effect of a Smartphone App on Hospital Admissions and Sedentary Behavior in Cardiac Rehabilitation Participants:ToDo-CR Randomized Controlled Trial

Background: People with coronary heart disease are at an increased risk of morbidity and mortality even if they attend cardiac rehabilitation. High sedentary behavior levels potentially contribute to this morbidity. Smartphone apps may be feasible to facilitate sedentary behavior reductions and lead to reduced health care use. Objective: We aimed to test the effect of a sedentary behavior change smartphone app (Vire app and ToDo-CR program) as an adjunct to cardiac rehabilitation on hospital admissions and emergency department (ED) presentations over 12 months. Methods: A multicenter, randomized controlled trial was conducted with 120 participants recruited from 3 cardiac rehabilitation programs. Participants were randomized 1:1 to cardiac rehabilitation plus the fully automated 6-month Vire app and ToDo-CR program (intervention) or usual care (control). The primary outcome was nonelective hospital admissions and ED presentations over 12 months. Secondary outcomes including accelerometer-measured sedentary behavior, BMI, waist circumference, and quality of life were recorded at baseline and 6 and 12 months. Logistic regression models were used to analyze the primary outcome, and linear mixed-effects models were used to analyze secondary outcomes. Data on intervention and hospital admission costs were collected, and the incremental cost-effectiveness ratios (ICERs) were calculated. Results: Participants were, on average, aged 62 (SD 10) years, and the majority were male (93/120, 77.5%). The intervention group were more likely to experience all-cause (odds ratio [OR] 1.54, 95% CI 0.58-4.10; P=.39) and cardiac-related (OR 3.26, 95% CI 0.84-12.55; P=.09) hospital admissions and ED presentations (OR 2.07, 95% CI 0.89-4.77; P=.09) than the control group. Despite this, cardiac-related hospital admission costs were lower in the intervention group over 12 months (Aus $252.40 vs Aus$859.38; P=.24; a currency exchange rate of Aus $1=US$0.69 is applicable). There were no significant between-group differences in sedentary behavior minutes per day over 12 months, although the intervention group completed 22 minutes less than the control group (95% CI -22.80 to 66.69; P=.33; Cohen d=0.21). The intervention group had a lower BMI (β=1.62; P=.05), waist circumference (β=5.81; P=.01), waist-to-hip ratio (β=.03, P=.03), and quality of life (β=3.30; P=.05) than the control group. The intervention was more effective but more costly in reducing sedentary behavior (ICER Aus $351.77) and anxiety (ICER Aus$10,987.71) at 12 months. The intervention was also more effective yet costly in increasing quality of life (ICER Aus $93,395.50) at 12 months. Conclusions: The Vire app and ToDo-CR program was not an outcome-effective or cost-effective solution to reduce all-cause hospital admissions or ED presentations in cardiac rehabilitation compared with usual care. Smartphone apps that target sedentary behavior alone may not be an effective solution for cardiac rehabilitation participants to reduce hospital admissions and sedentary behavior.</p

Modified Laminar Bone in Ampelosaurus atacis and Other Titanosaurs (Sauropoda): Implications for Life History and Physiology

BACKGROUND: Long bone histology of the most derived Sauropoda, the Titanosauria suggests that titanosaurian long bone histology differs from the uniform bone histology of basal Sauropoda. Here we describe the long bone histology of the titanosaur Ampelosaurus atacis and compare it to that of basal neosauropods and other titanosaurs to clarify if a special titanosaur bone histology exists. METHODOLOGY/PRINCIPAL FINDINGS: Ampelosaurus retains the laminar vascular organization of basal Sauropoda, but throughout most of cortical growth, the scaffolding of the fibrolamellar bone, which usually is laid down as matrix of woven bone, is laid down as parallel-fibered or lamellar bone matrix instead. The remodeling process by secondary osteons is very extensive and overruns the periosteal bone deposition before skeletal maturity is reached. Thus, no EFS is identifiable. Compared to the atypical bone histology of Ampelosaurus, the large titanosaur Alamosaurus shows typical laminar fibrolamellar bone. The titanosaurs Phuwiangosaurus, Lirainosaurus, and Magyarosaurus, although differing in certain features, all show this same low amount or absence of woven bone from the scaffolding of the fibrolamellar bone, indicating a clear reduction in growth rate resulting in a higher bone tissue organization. To describe the peculiar primary cortical bone tissue of Phuwiangosaurus, Ampelosaurus, Lirainosaurus, and Magyarosaurus, we here introduce a new term, "modified laminar bone" (MLB). CONCLUSIONS/SIGNIFICANCE: Importantly, MLB is as yet not known from extant animals. At least in Lirainosaurus and Magyarosaurus the reduction of growth rate indicated by MLB is coupled with a drastic body size reduction and maybe also a reduction in metabolic rate, interpreted as a result of dwarfing on the European islands during the Late Cretaceous. Phuwiangosaurus and Ampelosaurus both show a similar reduction in growth rate but not in body size, possibly indicating also a reduced metabolic rate. The large titanosaur Alamosaurus, on the other hand, retained the plesiomorphic bone histology of basal neosauropods

Impact of Duodenal-Jejunal Exclusion on Satiety Hormones

OBJECTIVE: Bariatric procedures that exclude the proximal small intestine lead to significant weight loss which is probably mediated by changes in hormones that alter appetite, such as peptide YY (PYY), ghrelin, cholecystokinin (CCK), and leptin. Here, the effect of the non-surgical duodenal-jejunal bypass liner (DJBL) on concentrations of hormones implicated in appetite control was investigated. SUBJECTS: A two-center prospective study was conducted between January and December 2010. Seventeen obese subjects with type 2 diabetes were treated with the DJBL for 24 weeks. Fasting concentrations of leptin and meal responses of plasma PYY, CCK, and ghrelin were determined prior to and after implantation of the DJBL. RESULTS: At baseline, subjects had an average body weight of 116.0 +/- 5.8 kg. One week after implantation, subjects had lost 4.3 +/- 0.6 kg (p < 0.01), which progressed to 12.7 +/- 1.3 kg at week 24 (p < 0.01). Postprandial concentrations of PYY and ghrelin increased (baseline vs. week 1 vs. week 24 PYY: 2.6 +/- 0.2 vs. 4.1 +/- 0.4 vs. 4.1 +/- 0.7 nmol/L/min and ghrelin: 7.8 +/- 1.8 vs. 11.0 +/- 1.8 vs. 10.6 +/- 1.8 ng/mL/min, all p < 0.05). In parallel, the CCK response decreased (baseline vs. week 1 vs. week 24: 434 +/- 51 vs. 229 +/- 52 vs. 256 +/- 51pmol/L/min, p < 0.01). Fasting leptin concentrations also decreased (baseline vs. week 24: 98 +/- 17 vs. 53 +/- 10 ng/mL, p < 0.01). CONCLUSIONS: DJBL treatment induces weight loss paralleled by changes in concentrations of hormones involved in appetite control