Expensive Strategy Research Articles

Risk-stratification in febrile infants 29 to 60\u2009days old: a cost-effectiveness analysis

BackgroundMultiple clinical prediction rules have been published to risk-stratify febrile infants ≤60 days of age for serious bacterial infections (SBI), which is present in 8-13% of infants. We evaluate the cost-effectiveness of strategies to identify infants with SBI in the emergency department.MethodsWe developed a Markov decision model to estimate outcomes in well-appearing, febrile term infants, using the following strategies: Boston, Rochester, Philadelphia, Modified Philadelphia, Pediatric Emergency Care Applied Research Network (PECARN), Step-by-Step, Aronson, and clinical suspicion. Infants were categorized as low risk or not low risk using each strategy. Simulated cohorts were followed for 1 year from a healthcare perspective. Our primary model focused on bacteremia, with secondary models for urinary tract infection and bacterial meningitis. One-way, structural, and probabilistic sensitivity analyses were performed. The main outcomes were SBI correctly diagnosed and incremental cost per quality-adjusted life-year (QALY) gained.ResultsIn the bacteremia model, the PECARN strategy was the least expensive strategy ($3671, 0.779 QALYs). The Boston strategy was the most cost-effective strategy and cost $9799/QALY gained. All other strategies were less effective and more costly. Despite low initial costs, clinical suspicion was among the most expensive and least effective strategies. Results were sensitive to the specificity of selected strategies. In probabilistic sensitivity analyses, the Boston strategy was most likely to be favored at a willingness-to-pay threshold of $100,000/QALY. In the urinary tract infection model, PECARN was preferred compared to other strategies and the Boston strategy was preferred in the bacterial meningitis model.ConclusionsThe Boston clinical prediction rule offers an economically reasonable strategy compared to alternatives for identification of SBI.

Automation is a 10-Step Competitive Necessity

Incredibly, many executives still believe that the adoption of artificial intelligence (AI) and machine learning (ML) will be relatively slow.1,4 This miscalculation is potentially threatening to a company's very existence. Business models and processes will change radically as AI and ML continue to strengthen. It is a business-technology trend that is undeniable and unstoppable. Predictions about the “The Future of Work” and the “4th Industrial Revolution” reduce AI and ML to a single word: automation. In addition to the other application areas of AI and ML, companies that embrace automation will win; those that do not will lose. The automation arms race has already begun. New business models and countless business processes will be automated to save money and make money—the perfect twin metrics. Lagging here will force an expensive catch-up strategy (where nothing good ever happens).

Optimal Control and Cost‐Effectiveness Strategies of Malaria Transmission with Impact of Climate Variability

We proposed in this study a deterministic mathematical model of malaria transmission with climate variation factor. In the first place, fundamental properties of the model, such as positivity of solution and boundedness of the biological feasibility of the model, were proved whenever all initial data of the states were nonnegative. The next‐generation matrix method is used to compute a basic reproduction number with respect to the disease‐free equilibrium point. The Jacobian matrix and the Lyapunov function are used to check the local and global stability of disease‐free equilibriums. If the basic reproduction number is less than one, the model’s disease‐free equilibrium points are both locally and globally asymptotically stable; otherwise, an endemic equilibrium occurs. The results of the sensitivity analysis of the basic reproduction numbers were obtained, and its biological interpretation was provided. The existence of bifurcation was discussed, and the model exhibits forward and backward bifurcations with respect to the first and second basic reproduction numbers, respectively. Secondly, using the maximum principle of Pontryagin, the optimal malaria reduction strategies are described with three control measures, namely, treated bed nets, infected human treatment, and indoor residual spraying. Finally, based on numerical simulations of the optimality system, the combination of treatment and indoor spraying is the most efficient and least expensive strategy for malaria eradication.

58. Cost-Effectiveness of Emerging Antibiotic Strategies for the Treatment of Drug-Use Associated Infective Endocarditis

BackgroundDrug use-associated infective endocarditis (DUA-IE) is typically treated with 4-6 weeks of in hospital intravenous antibiotics (IVA). Outpatient parenteral antimicrobial therapy (OPAT) and partial oral antibiotics (PO) may be as effective as IVA, though long-term outcomes and costs remain unknown. We evaluated the clinical outcomes and cost-effectiveness of four antibiotic treatment strategies for DUA-IE. MethodsWe used a validated microsimulation model to compare: 1) 4-6 weeks of inpatient IVA along with opioid detoxification, status quo (SQ); 2) 4-6 weeks of inpatient IVA along with inpatient addiction care services (ACS) which offers medications for opioid use disorder (SQ with ACS); 3) 3 weeks of inpatient IVA with ACS followed by OPAT (OPAT); and 4) 3 weeks of IVA with ACS followed by PO antibiotics (PO). We derived model inputs from clinical trials and observational cohorts. All patients were eligible for either in-home or post-acute care OPAT. Outcomes included life years (LYs), discounted costs, incremental cost-effectiveness ratios (ICERs), proportion of DUA-IE cured, and mortality attributable to DUA-IE. Costs (&US) were annually discounted at 3%. We performed probabilistic sensitivity analyses (PSA) to address uncertainty.ResultsThe SQ scenario resulted in 18.64 LY at a cost of &416,800/person with 77.4% hospitalized DUA-IE patients cured and 5% of deaths in the population were attributable to DUA-IE. Life expectancy was extended by each strategy: 0.017y in SQ with ACS, 0.011 in OPAT, and 0.024 in PO. The PO strategy provided the highest cure rate (80.2%), compared to 77.9% in SQ with ACS and 78.5% in OPAT and X in SQ. OPAT was the least expensive strategy at &412,300/person, Compared to OPAT, PO had an ICER of &141,500/LY. Both SQ strategies provided worse clinical outcomes for money invested than either OPAT or PO (dominated). All scenarios decreased deaths attributable to DUA-IE compared to SQ. Findings were robust in PSA.Table 1 Selected cost and clinical outcomes comparing treatment strategies for drug-use associated infective endocarditis including the status quo, status quo with addiction care services, outpatient parenteral antimicrobial therapy, and partial oral antibiotics.ConclusionTreating DUA-IE with OPAT along with ACS increases the number of people completing treatment, decreases DUA-IE mortality, and is cost-saving compared to the status quo. The PO strategy also improves clinical outcomes, but may not be cost-effective at the willingness-to-pay threshold of &100,000. Disclosures Simeon D. Kimmel, MD, MA, Abt Associates for a Massachusetts Department of Public Health project to improve access to medications for opioid use disorder in nursing facilities (Consultant)

AraC-type regulators HilC and RtsA are directly controlled by an intestinal fatty acid to regulate Salmonella invasion.

Invasion of the intestinal epithelium is an essential but energetically expensive survival strategy and is, therefore, tightly regulated by using specific cues from the environment. The enteric pathogen Salmonella controls its invasion machinery through the elegant coordination of three AraC-type transcription activators, HilD, HilC, and RtsA. Most environmental signals target HilD to control invasion, whereas HilC and RtsA are known only to augment these effects on HilD. Here we show that a fatty acid found in the murine colon, cis-2-hexadecenoic acid (c2-HDA), represses Salmonella invasion by directly targeting HilC and RtsA, in addition to HilD. c2-HDA directly binds each of these regulators and inhibits their attachment to DNA targets, repressing invasion even in the absence of HilD. Fatty acid binding, however, does not affect HilC and RtsA protein stability, unlike HilD. Importantly, we show that HilC and RtsA are highly effective in restoring HilD production and invasion gene expression after elimination of the repressive fatty acid c2-HDA. Together, these results illuminate a precise mechanism by which HilC and RtsA may modulate invasion as Salmonella navigates through different regions of the intestine, contributing to our understanding of how this enteric pathogen senses and adapts to a diverse intestinal environment while maintaining its virulence.

Cost-Effectiveness of Treatment Strategies for High-Risk Prostate Cancer

Patients with high-risk prostate cancer (HRPC) have many treatment options: external beam radiotherapy (EBRT) with or without low-dose rate (LDR) or high-dose rate (HDR) brachytherapy boost, ultra-hypofractionated radiotherapy (UH), or radical prostatectomy (RP). No randomized evidence supports an overall survival (OS) benefit of one option relative to the others, so appropriate treatment must consider patient life expectancy, quality of life, and cost. We compare these treatments to determine the technique resulting in the optimal quality-adjusted life years (QALYs) and cost-effectiveness.A Markov model was developed to simulate treatment options and downstream events for HRPC. The primary endpoints were average accumulated costs and QALYs. The cost analysis considered all aspects of therapy, including treatments and side effects. Secondary endpoints included biochemical recurrence (BCR) and OS. Five treatment approaches were considered: moderately hypofractionated EBRT + 18 months androgen deprivation therapy (ADT), EBRT + LDR boost with 12 months ADT, EBRT + HDR boost with 12 months ADT, UH with 18 months ADT, and RP + salvage radiotherapy (SRT) after BCR. Treatment outcome and toxicity data were determined from the ASCENDE-RT, Hoskin et al. HDR, HYPO-RT-PC, and ProtecT trials. Efforts were made to specifically assess outcomes for HRPC patients. One-way sensitivity analyses were performed, including the rates of death from non-prostate cancer, ADT use, and SRT after RP.The base case was simulated for 15 years (Table 1). EBRT + brachytherapy boost (either HDR or LDR) was the most cost-effective treatment option with equivalent QALYs to RP and lower total costs. Over a 5-year timeframe, QALYs were comparable across all strategies, but UH had the lowest cost. At 10 years, RP and brachytherapy boost showed similar QALYs and cost. On sensitivity analysis, increasing rates of metastatic progression from BCR and decreased patient compliance with recommended ADT led to increasing cost-effectiveness of brachytherapy boost. High SRT rates (≥ 75%) after BCR following RP led to eventual ascendancy of RP over brachytherapy boost in both cost and QALYs. Without SRT, RP was the most expensive strategy with comparable outcomes to EBRT alone. No treatment strategy resulted in improved OS over the other treatments.Our analysis suggests that brachytherapy boost in patients with HRPC is the most cost-effective strategy over a 15-year horizon. Over shorter timeframes, UH is the most cost-effective treatment. Finally, high rates of SRT are vital to optimizing outcomes for patients after RP.

Parental investment as social agency and catalyst to complexity

Re-examination of the relationships between diets as inferred isotopically and grave goods in light of new data has revealed the importance of parental investment for Early Neolithic populations in Cis-Baikal, Siberia. The Kitoi Culture developed and maintained a flexible but expensive broad-spectrum subsistence strategy. Moderately high extrinsic risk factors produced periodic famines and metabolic stress evidence in skeletons. The small-scale efforts of parents to support their offspring through increased breast milk and plant food provisioning led to a restructuring of subsistence priorities with ramifications for group structuring over the course of centuries.

Study protocol for a type III hybrid effectiveness-implementation trial of strategies to implement firearm safety promotion as a universal suicide prevention strategy in pediatric primary care

BackgroundInsights from behavioral economics, or how individuals’ decisions and behaviors are shaped by finite cognitive resources (e.g., time, attention) and mental heuristics, have been underutilized in efforts to increase the use of evidence-based practices in implementation science. Using the example of firearm safety promotion in pediatric primary care, which addresses an evidence-to-practice gap in universal suicide prevention, we aim to determine: is a less costly and more scalable behavioral economic-informed implementation strategy (i.e., “Nudge”) powerful enough to change clinician behavior or is a more intensive and expensive facilitation strategy needed to overcome implementation barriers?MethodsThe Adolescent and child Suicide Prevention in Routine clinical Encounters (ASPIRE) hybrid type III effectiveness-implementation trial uses a longitudinal cluster randomized design. We will test the comparative effectiveness of two implementation strategies to support clinicians’ use of an evidence-based firearm safety practice, S.A.F.E. Firearm, in 32 pediatric practices across two health systems. All pediatric practices in the two health systems will receive S.A.F.E. Firearm materials, including training and cable locks. Half of the practices (k = 16) will be randomized to receive Nudge; the other half (k = 16) will be randomized to receive Nudge plus 1 year of facilitation to target additional practice and clinician implementation barriers (Nudge+). The primary implementation outcome is parent-reported clinician fidelity to the S.A.F.E Firearm program. Secondary implementation outcomes include reach and cost. To understand how the implementation strategies work, the primary mechanism to be tested is practice adaptive reserve, a self-report practice-level measure that includes relationship infrastructure, facilitative leadership, sense-making, teamwork, work environment, and culture of learning.DiscussionThe ASPIRE trial will integrate implementation science and behavioral economic approaches to advance our understanding of methods for implementing evidence-based firearm safety promotion practices in pediatric primary care. The study answers a question at the heart of many practice change efforts: which strategies are sufficient to support change, and why? Results of the trial will offer valuable insights into how best to implement evidence-based practices that address sensitive health matters in pediatric primary care.Trial registrationClinicalTrials.gov, NCT04844021. Registered 14 April 2021.

Toolkit and distance coaching strategies: a mixed methods evaluation of a trial to implement care coordination quality improvement projects in primary care

BackgroundCare coordination tools and toolkits can be challenging to implement. Practice facilitation, an active but expensive strategy, may facilitate toolkit implementation. We evaluated the comparative effectiveness of distance coaching, a form of practice facilitation, for improving the implementation of care coordination quality improvement (QI) projects.MethodsWe conducted a mixed methods evaluation of the Coordination Toolkit and Coaching (CTAC) initiative. Twelve matched US Veterans Health Administration primary care clinics were randomized to receive coaching and an online care coordination toolkit (“coached”; n = 6) or access to the toolkit only (“non-coached”; n = 6). We did interviews at six, 12, and 18 months. For coached sites, we‘ly collected site visit fieldnotes, prospective coach logs, retrospective coach team debriefs, and project reports. We employed matrix analysis using constructs from the Consolidated Framework for Implementation Research and a taxonomy of outcomes. We assessed each site’s project(s) using an adapted Complexity Assessment Tool for Systematic Reviews.ResultsEleven sites implemented a local CTAC project. Eight sites (5 coached, 3 non-coached) used at least one tool from the toolkit. Coached sites implemented significantly more complex projects than non-coached sites (11.5 vs 7.5, 95% confidence interval 1.75–6.25, p < 0.001); engaged in more formal implementation processes (planning, engaging, reflecting and evaluating); and generally had larger, more multidisciplinary QI teams. Regardless of coaching status, sites focused on internal organizational improvement and low-intensity educational projects rather than the full suite of care coordination tools. At 12 months, half the coached and non-coached sites had clinic-wide project implementation; the remaining coached sites had implemented most of their project(s), while the remaining non-coached sites had either not implemented anything or conducted limited pilots. At 18 months, coached sites reported ongoing effort to monitor, adapt, and spread their CTAC projects, while non-coached sites did not report much continuing work. Coached sites accrued benefits like improved clinic relationships and team QI skill building that non-coached sites did not describe.ConclusionsCoaching had a positive influence on QI skills of (and relationships among) coached sites’ team members, and the scope and rigor of projects. However, a 12-month project period was potentially too short to ensure full project implementation or to address cross-setting or patient-partnered initiatives.Trial registrationNCT03063294.

Optimal Control of Insect Populations

We consider some optimal control problems for systems governed by linear parabolic PDEs with local controls that can move along the domain region Ω of the plane. We prove the existence of optimal paths and also deduce the first order necessary optimality conditions, using the Dubovitskii–Milyutin’s formalism, which leads to an iterative algorithm of the fixed-point kind. This problem may be considered as a model for the control of a mosquito population existing in a given region by using moving insecticide spreading devices. In this situation, an optimal control is any trajectory or path that must follow such spreading device in order to reduce the population as much as possible with a reasonable not too expensive strategy. We illustrate our results by presenting some numerical experiments.

Control with uncertain data of socially structured compartmental epidemic models

The adoption of containment measures to reduce the amplitude of the epidemic peak is a key aspect in tackling the rapid spread of an epidemic. Classical compartmental models must be modified and studied to correctly describe the effects of forced external actions to reduce the impact of the disease. The importance of social structure, such as the age dependence that proved essential in the recent COVID-19 pandemic, must be considered, and in addition, the available data are often incomplete and heterogeneous, so a high degree of uncertainty must be incorporated into the model from the beginning. In this work we address these aspects, through an optimal control formulation of a socially structured epidemic model in presence of uncertain data. After the introduction of the optimal control problem, we formulate an instantaneous approximation of the control that allows us to derive new feedback controlled compartmental models capable of describing the epidemic peak reduction. The need for long-term interventions shows that alternative actions based on the social structure of the system can be as effective as the more expensive global strategy. The timing and intensity of interventions, however, is particularly relevant in the case of uncertain parameters on the actual number of infected people. Simulations related to data from the first wave of the recent COVID-19 outbreak in Italy are presented and discussed.

Rethinking the ST-GCNs for 3D skeleton-based human action recognition

The skeletal data has been an alternative for the human action recognition task as it provides more compact and distinct information compared to the traditional RGB input. However, unlike the RGB input, the skeleton data lies in a non-Euclidean space that traditional deep learning methods are not able to use their fullest potential. Fortunately, with the emerging trend of Geometric deep learning, the spatial-temporal graph convolutional network (ST-GCN) has been proposed to deal with the action recognition problem from skeleton data. ST-GCN and its variants fit well with skeleton-based action recognition and are becoming the mainstream frameworks for this task. However, the efficiency and the performance of the task are hindered by either fixing the skeleton joint correlations or providing a computational expensive strategy to construct a dynamic topology for the skeleton. We argue that many of these operations are either unnecessary or even harmful for the task. By theoretically and experimentally analysing the state-of-the-art ST-GCNs, we provide a simple but efficient strategy to capture the global graph correlations and thus efficiently model the representation of the input graph sequences. Moreover, the global graph strategy also reduces the graph sequence into the Euclidean space, thus a multi-scale temporal filter is introduced to efficiently capture the dynamic information. With the method, we are not only able to better extract the graph correlations with much fewer parameters (only 12.6% of the current best), but we also achieve a superior performance. Extensive experiments on current largest 3D datasets, NTU-RGB+D and NTU-RGB+D 120, demonstrate the ability of our network to perform efficient and lightweight priority on this task.

Insights into low-carbon hydrogen production methods: Green, blue and aqua hydrogen

The primary aim of this study is to provide insights into different low-carbon hydrogen production methods. Low-carbon hydrogen includes green hydrogen (hydrogen from renewable electricity), blue hydrogen (hydrogen from fossil fuels with CO2 emissions reduced by the use of Carbon Capture Use and Storage) and aqua hydrogen (hydrogen from fossil fuels via the new technology). Green hydrogen is an expensive strategy compared to fossil-based hydrogen. Blue hydrogen has some attractive features, but the CCUS technology is high cost and blue hydrogen is not inherently carbon free. Therefore, engineering scientists have been focusing on developing other low-cost and low-carbon hydrogen technology. A new economical technology to extract hydrogen from oil sands (natural bitumen) and oil fields with very low cost and without carbon emissions has been developed and commercialized in Western Canada. Aqua hydrogen is a term we have coined for production of hydrogen from this new hydrogen production technology. Aqua is a color halfway between green and blue and thus represents a form of hydrogen production that does not emit CO2, like green hydrogen, yet is produced from fossil fuel energy, like blue hydrogen. Unlike CCUS, blue hydrogen, which is clearly compensatory with respect to carbon emissions as it captures, uses and stores produced CO2, the new production method is transformative in that it does not emit CO2 in the first place. In order to promote the development of the low-carbon hydrogen economy, the current challenges, future directions and policy recommendations of low-carbon hydrogen production methods including green hydrogen, blue hydrogen, and aqua hydrogen are investigated in the paper.

Cost-Effectiveness of Multitarget Stool DNA Testing vs Colonoscopy or Fecal Immunochemical Testing for Colorectal Cancer Screening in Alaska Native People

ObjectiveTo estimate the cost-effectiveness of multitarget stool DNA testing (MT-sDNA) compared with colonoscopy and fecal immunochemical testing (FIT) for Alaska Native adults. Patients and MethodsA Markov model was used to evaluate the 3 screening test effects over 40 years. Outcomes included colorectal cancer (CRC) incidence and mortality, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). The study incorporated updated evidence on screening test performance and adherence and was conducted from December 15, 2016, through November 6, 2019. ResultsWith perfect adherence, CRC incidence was reduced by 52% (95% CI, 46% to 56%) using colonoscopy, 61% (95% CI, 57% to 64%) using annual FIT, and 66% (95% CI, 63% to 68%) using MT-sDNA. Compared with no screening, perfect adherence screening extends life by 0.15, 0.17, and 0.19 QALYs per person with colonoscopy, FIT, and MT-sDNA, respectively. Colonoscopy is the most expensive strategy: approximately $110 million more than MT-sDNA and $127 million more than FIT. With imperfect adherence (best case), MT-sDNA resulted in 0.12 QALYs per person vs 0.05 and 0.06 QALYs per person by FIT and colonoscopy, respectively. Probabilistic sensitivity analyses supported the base-case analysis. Under varied adherence scenarios, MT-sDNA either dominates or is cost-effective (ICERs, $1740-$75,868 per QALY saved) compared with FIT and colonoscopy. ConclusionEach strategy reduced costs and increased QALYs compared with no screening. Screening by MT-sDNA results in the largest QALY savings. In Markov model analysis, screening by MT-sDNA in the Alaska Native population was cost-effective compared with screening by colonoscopy and FIT for a wide range of adherence scenarios.

Sepsis and the evolution of human increased sensitivity to lipopolysaccharide.

Among mammals, humans are exquisitely sensitive to lipopolysaccharide (LPS), an environmentally pervasive bacterial cell membrane component. Very small doses of LPS trigger powerful immune responses in humans and can even initiate symptoms of sepsis. Close evolutionary relatives such as African and Asian monkeys require doses that are an order of magnitude higher to do the same. Why humans have evolved such an energetically expensive antimicrobial strategy is a question that biological anthropologists are positioned to help address. Here we compare LPS sensitivity in primate/mammalian models and propose that human high sensitivity to LPS is adaptive, linked to multiple immune tactics against pathogens, and part of multi-faceted anti-microbial strategy that strongly overlaps with that of other mammals. We support a notion that LPS sensitivity in humans has been driven by microorganisms that constitutively live on us, and has been informed by human behavioral changes over our species' evolution (e.g., meat eating, agricultural practices, and smoking).

Recruitment of Participants for a 3D Virtual Supermarket: Cross-sectional Observational Study.

BackgroundVirtual supermarkets offer a practical and affordable setting to test the efficacy of different pricing and nudging strategies before they are implemented in the real world. Despite the advantages of using virtual supermarkets for this purpose, conducting studies in online settings is challenging with regard to recruitment and retention of sufficient and suitable participants.ObjectiveTo describe cost, time, and retention with regard to participants recruited using various strategies and potential sociodemographic differences between participants recruited via different strategies.MethodsThis cross-sectional study used data from a randomized controlled trial in which 455 Dutch adults with low and high educational levels were invited to shop 5 times in a 3D virtual supermarket. Participants were recruited via social media and flyers. A log that tracked the costs of and time spent on the different recruitment strategies was kept by the study team. Outcome measures included the cost of recruitment strategies, the time investment by researchers, and recruitment and attrition rates of participants in the study.ResultsThe median age of study completers was 31.0 (IQR 25.0) and 157 out of 346 study completers (45.4%) were highly educated. Out of the 455 included participants, 235 (51.6%) were recruited via social media campaigns, 131 (28.8%) via home-delivered flyers, 38 (8.4%) via flyers directly distributed by the study team, and 46 (10.1%) via word-of-mouth. Of all paid recruitment strategies, social media campaigns were the cheapest and least time-consuming, whereas the distribution of flyers by the study team was the most expensive and time-consuming recruitment strategy. Age, sex, overweight status, employment situation, and number of adults within the household varied by recruitment strategy.ConclusionsUsing different recruitment strategies resulted in the efficient recruitment of a representative study sample and retention of participants was relatively high. While “word-of-mouth” was the most cost- and time-effective recruitment strategy, using only one type of recruitment strategy could result in a demographically skewed study population.

Fire frequency effects on cleistogamy expression and progeny performance in Cologania broussonetii.

Increased fire frequency usually erodes microenvironmental conditions, causing a drastic limitation of edaphic resources. Thus, the production of permanently closed-small flowers (cleistogamous, CL) should increase in sites with high fire frequency as this implies a less expensive reproductive assurance strategy. However, because open, insect-pollinated flowers (chasmogamous, CH) have the potential capacity to outcross via pollinators, CH progeny produced at any site should outperform selfed CL progeny. We evaluate the effect of fire frequency on the relative production of CL/CH flowers and fruits, and their seed set, along with several progeny performance parameters in Cologania broussonetii (Fabaceae), a resprouting herb with dimorphic cleistogamy native to the Chaco Serrano. Fire frequency increased cleistogamy expression, reaching extreme levels in high fire frequency sites. Seed set was similarly high for both CH and CL flowers in the unburned condition, while in burned sites the few developed CH flowers set more seeds than CL flowers. However, progeny performance was similar between CH and CL progeny at each and across all fire frequency conditions. Cleistogamy expression in C. broussonetii is maximized in abiotically degraded frequently burned habitats, although the selfed CL progeny is as successful as potentially outcrossed CH progeny. Fire frequency may decreased floral size and abundance, selecting for autogamous reproduction, which restricts not only the genetic potential of plant populations but also the resources offered to pollinators. At the community level, increased cleistogamy expression may potentially have negative implications for non-cleistogamous, more outcrossing species surviving in frequently burned environments.

Early cholangioscopy-assisted electrohydraulic lithotripsy in difficult biliary stones is cost-effective.

Background and Aims:Single-operator cholangioscopy-assisted electrohydraulic lithotripsy (SOC-EHL) is effective and safe in difficult choledocholithiasis. The optimal timing of SOC-EHL use, however, in refractory stones has not been elucidated. The following aims to determine the most cost-effective timing of SOC-EHL introduction in the management of choledocholithiasis.Methods:A cost-effectiveness model was developed assessing three strategies with a progressively delayed introduction of SOC-EHL. Probability estimates of patient pathways were obtained from a systematic review. The unit of effectiveness is complete ductal clearance without need for surgery. Cost is expressed in 2018 US dollars and stem from outpatient US databases.Results:The three strategies achieved comparable ductal clearance rates ranging from 97.3% to 99.7%. The least expensive strategy is to perform SOC-EHL during the first endoscopic retrograde cholangiography pancreatography (ERCP) (SOC-1: 18,506$). The strategy of postponing the use of SOC-EHL to the third ERCP (SOC-3) is more expensive (US$18,895) but is 2% more effective. (0.9967). SOC-EHL during the second ERCP in the model (SOC-2) is the least cost-effective. Sensitivity analyses show altered conclusions according to the cost of SOC-EHL, effectiveness of conventional ERCP, and altered willingness-to-pay (WTP) thresholds with early SOC-1 being the most optimal approach below a WTP cut-off of US$20,295.Conclusions:Early utilization of SOC-EHL (SOC-1) in difficult choledocholithiasis may be the least costly strategy with an effectiveness approximating those achieved with a delayed approach where one or more conventional ERCP(s) are reattempted prior to SOC-EHL introduction.

Pharmacologic, Dietary, and Psychological Treatments for Irritable Bowel Syndrome With Constipation: Cost Utility Analysis.

Introduction. Irritable bowel syndrome (IBS) is the most common gastroenterology referral and one of the most common gastrointestinal complaints in primary care. We performed a cost-utility analysis of the most common treatments available in general practice for IBS with constipation (IBS-C), the most expensive IBS subtype. Methods. We developed a decision analytic model evaluating guideline-recommended and Food and Drug Administration–approved drugs, supplements, and dietary/psychological interventions. Model inputs were derived from “global symptom improvement” outcomes in systematic reviews of clinical trials. Costs were derived from national datasets. Analysis was performed with a 1-year time horizon from patient and payer perspectives. We analyzed a prototypical managed-care health plan with no cost-sharing to the patient. Results. From a payer perspective, global IBS treatments (including low FODMAP, cognitive behavioral therapy [CBT], neuromodulators), which are not specific to the IBS-C bowel subtype were less expensive than on-label prescription drug treatments. From a patient perspective, on-label prescription drug treatment with linaclotide was the least expensive treatment strategy. Drug prices and costs to manage untreated IBS-C were most important determinants of payer treatment preferences. Effects of treatment on missed work-days and need for repeated appointments to complete treatment were the most important determinants of treatment preference to patients. Discussion. Due mostly to prescription drug prices, neuromodulators, low FODMAP, and CBT appear cost-effective compared to on-label drug treatments from a payer perspective in cost-utility analysis. These findings may explain common treatment barriers in clinical practice.

Understanding evidence-based lead mitigation: Is the lead mitigation advice and strategies being communicated to citizens evidence-based?

Background and Hypothesis: The CDC has declared that there is no safe blood lead level for a child, but still approximately 37 million homes are lead-contaminated of which 4 million are home to small children. Lead abatement is an expensive strategy to remove all lead hazards rendering a home lead-free. Many of these lead-contaminated homes are in lower socioeconomic areas which makes lead abatement nearly impossible. Given the expense of lead abatement, low-cost interim controls are needed to reduce lead exposure thus creating a lead-safe home. We hypothesize that updated lead mitigation strategies need pursued, and there is a large disparity of lead information disseminated between health departments. &#x0D; &#x0D; Project Methods: Using JSTOR and Boolean criteria, we conducted a systematic literature review on evidence-based, do-it-yourself (DIY) lead mitigation strategies for sources of lead contamination. Once the literature review was completed, QualtricsR was used to quantitatively and qualitatively evaluate the 50 state health department’s websites for lead policy, user friendliness, and recommended lead interim controls as compared to the literature review. &#x0D; &#x0D; Results: Results from the literature indicate that there is a lack of current information regarding new strategies for lead mitigation. Research prior to the year 2000 shows that cleaning flat surfaces by wet mopping, washing hands frequently, mulching, removing shoes before entering the home, and painting over deteriorating paint significantly reduces lead accumulation in the home. Preliminary results from the website review found that there is no baseline of uniform information being distributed, and evidence-based practices are not included for each state health department. &#x0D; &#x0D; Potential Impact: The lack of continuity nationwide for lead mitigation showcases that families are not receiving all of the information that research has to offer to help keep their homes safe. This research indicates that there is a need for national lead policies and recommendations, so each family in the U.S. is equally informed.