Simulating cost-effectiveness of fluoride varnish during well-child visits for Medicaid-enrolled children

OBJECTIVE: To examine the cost-effectiveness of fluoride varnish application by medical providers when implemented within a well-child periodicity schedule for Medicaid-enrolled children. DESIGN: Cost-effectiveness was analyzed using published probabilities and costs. Input parameters included the effectiveness of fluoride varnish (35.4%) applied according to the well-child periodicity schedule up to 3 years of age at $16.00 per application, annual caries increment (14%), age-specific dental care usage rates (0.2% at 9 months to 19% at 42 months), and age-related nonhospital treatment costs ($292.00-$503.00) and hospital treatment costs ($2191.00-$2940.00). Sensitivity analysis was conducted to assess the effects for varying input parameters. SETTING: Well-child visits during primary care. PARTICIPANTS: Children aged 9 to 42 months. INTERVENTION: Application of universal fluoride varnish (fluoride varnish-all) at 9, 18, 24, and 36 months vs no intervention (fluoride varnish-none) was compared. MAIN OUTCOME MEASURES: Cost per month without cavities and treatment averted during the first 42 months of life from a Medicaid payer's perspective. RESULTS: Fluoride varnish improved clinical outcomes by 1.52 cavity-free months but at a cost of $7.18 for each cavity-free month gained per child and $203 for each treatment averted. Considerable uncertainty existed for some parameters. Fluoride varnish was cost saving when dental services and nonhospital treatment costs were 1.5 to 2 times greater, respectively, than our base case estimate. CONCLUSIONS: Based on these assumptions, fluoride varnish use in the medical setting is effective in reducing early childhood caries in low-income populations but is not cost saving in the first 42 months of life. Potential total cost reductions with varying parameters suggest that evaluations using a longitudinal cohort are needed.     

Study of MICA alleles in 201 African Americans by multiplexed single nucleotide extension (MSNE) typing

We have developed a method for major histocompatibility complex class I chain-related gene A (MICA) genotyping using multiplexed single nucleotide extension (MSNE) and flow cytometric analysis of an array of fluorescent microspheres. This technique employs a polymerase chain reaction-derived target DNA containing all the polymorphic sites of MICA, synthetic complementary primers, biotinylated dideoxynucleotide triphosphate, fluorescent reporter molecules (streptavidin-phycoerythrin), and thermophilic DNA polymerase. Genomic DNA was amplified by MICA locus-specific primers and the MSNE reactions were carried out in the presence of 30 MSNE primers used to assay polymorphisms in exons 2, 3, and 4 of the MICA genes. Thirty-two previously typed cell lines were used as reference material. The MICA gene frequencies among 201 African-American unrelated donors were determined. Of 51 previously known alleles, 18 were observed in African-Americans, compared to 16 that were found in North American Caucasians and 9 in South American Indians, suggesting a more diversified allelic distribution in African-Americans. MICA*00201 and MICA*00801 were the two most frequent alleles in African-Americans. We observed a high degree of linkage disequilibrium between certain alleles of MICA and of human leukocyte antigen-B in the African-American population. The methodology described here offers a powerful new approach to DNA typing of the MICA alleles.     

Design of Performance-Based Concrete Using Sand Reclaimed from Construction and Demolition Waste–Comparative Study of Czechia and India

The main goal and novelty of this study is to show the transferability of practices and experiences with the use of reclaimed sand worldwide in the case in two different regions, the Czech Republic and India, which is necessary for both regions due to the sand availability (Czech Republic) and illegal sand mining including criminal offences (India). Due to the deteriorating environmental impacts associated with sand mining, finding substitution possibilities for natural sand is becoming more important worldwide. It is realized that the reuse of construction demolition waste concrete is inevitable in the pursuit of circular concrete and cleaner production, envisioned by the United Nations (UN) as the attainment of ensuring sustainable consumption and production patterns (Sustainable Development Goal 12-SDG 12) with an inclusive approach of partnerships to achieve the goal (Sustainable Development Goal 17-SDG 17) for the validation of results. The basic material properties of reclaimed sand were examined, and its impact on the physical, mechanical, and durability properties of concrete with complete replacement of sand was evaluated. Generally, a slight decline in properties of concrete with fine recycled aggregate was found. No significant decrease was found from usage possibility in the point of view of its utilization in specific structures and conditions. The research shows the slight differences of results between the Czech and Indian investigations, which are not essential for the transferability of the results.     

Modulation of ADP-induced platelet activation by aspirin and pravastatin: role of lectin-like oxidized low-density lipoprotein receptor-1, nitric oxide, oxidative stress, and inside-out integrin signaling

Lectin-like oxidized low-density lipoprotein (LDL) receptor-1 (LOX-1), a receptor for oxidized-LDL, is up-regulated in activated endothelial cells, and it plays a role in atherothrombosis. However, its role in platelet aggregation is unclear. Both aspirin and HMG CoA reductase inhibitors (statins) reduce LOX-1 expression in endothelial cells. In this study, we investigated the effect of aspirin and pravastatin on LOX-1 expression on plate-lets. After ADP stimulation, mean fluorescence intensity of LOX-1 expression on platelets increased 1.5- to 2.0-fold. Blocking LOX-1 inhibited ADP-induced platelet aggregation in a concentration- and time-dependent manner. We also established that LOX-1 is important for ADP-stimulated inside-out activation of platelet alpha(IIb)beta(3) and alpha(2)beta(1) integrins (fibrinogen receptors). The specificity of this interaction was determined by arginine-glycine-aspartate-peptide inhibition. Furthermore, we found that LOX-1 inhibition of integrin activation is mediated by inhibition of protein kinase C activity. In other experiments, treatment with aspirin (1-10 mM) and pravastatin (1-5 microM) reduced platelet LOX-1 expression, with a synergistic effect of the combination of aspirin and pravastatin. Aspirin and pravastatin both reduced reactive oxygen species (ROS) released by activated platelets measured as malonyldialdehyde (MDA) release and nitrate/nitrite ratio. Aspirin and pravastatin also enhanced nitric oxide (NO) release measured as nitrite/nitrite + nitrate (NOx) ratio in platelet supernates. Small concentrations of aspirin and pravastatin had a synergistic effect on the inhibition of MDA release and enhancement of nitrite/NOx. Thus, LOX-1 is important for ADP-mediated platelet integrin activation, possibly through protein kinase C activation. Furthermore, aspirin and pravastatin inhibit LOX-1 expression on platelets in part by favorably affecting ROS and NO release from activated platelets.     

Role of steroid maintenance in sensitized kidney transplant recipients

AIM: To evaluate whether there is a threshold sensitization level beyond which benefits of chronic steroid maintenance (CSM) emerge.METHODS: Using Organ Procurement and Transplant Network/United Network of Organ Sharing database, we compared the adjusted graft and patient survivals for CSM vs early steroid withdrawal (ESW) among patients who underwent deceased-donor kidney (DDK) transplantation from 2000 to 2008 who were stratified by peak-panel reactive antibody (peak-PRA) titers (0%-30%, 31%-60% and > 60%). All patients received perioperative induction therapy and maintenance immunosuppression based on calcineurin inhibitor (CNI) and mycophenolate mofetil (MMF).RESULTS: The study included 42851 patients. In the 0%-30% peak-PRA class, adjusted over-all graft-failure (HR 1.11, 95%CI: 1.03-1.20, P = 0.009) and patient-death (HR 1.29, 95%CI: 1.16-1.43, P < 0.001) risks were higher and death-censored graft-failure risk (HR 1.06, 95%CI: 0.98-1.14, P = 0.16) similar for CSM (n = 25218) vs ESW (n = 7399). Over-all (HR 1.04, 95%CI: 0.85-1.28, P = 0.70) and death-censored (HR 0.97, 95%CI: 0.78-1.21, P = 0.81) graft-failure risks were similar and patient-death risk (HR 1.39, 95%CI: 1.03-1.87, P = 0.03) higher for CSM (n = 3495) vs ESW (n = 850) groups for 31%-60% peak-PRA class. In the > 60% peak-PRA class, adjusted overall graft-failure (HR 0.90, 95%CI: 0.76-1.08, P = 0.25) and patient-death (HR 0.92, 95%CI: 0.71-1.17, P = 0.47) risks were similar and death-censored graft-failure risk lower (HR 0.84, 95%CI: 0.71-0.99, P = 0.04) for CSM (n = 4966) vs ESW (n = 923).CONCLUSION: In DDK transplant recipients who underwent perioperative induction and CNI/MMF maintenance, CSM appears to be associated with increased risk for death with functioning graft in minimally-sensitized patients and improved death-censored graft survival in highly-sensitized patients.     

Pediatric Lupus: Varied Haematological Picture and Presentation

Systemic lupus erythematosus (SLE) is a chronic, multisystem, autoimmune disease characterized by periods of increased disease activity caused by inflammation of blood vessels and connective tissue. Pediatric patients with SLE have a more severe clinical course when compared with adults. Patients commonly present with rash, fever, and arthritis, although the presentation may be unpredictable. Hematological findings are more predominant in children than adults. Thirty-nine percent of children with SLE will develop hematological abnormalities, one of the American Rheumatic Association criteria for classifying the disease. In our case series we found varied hematological picture and presentation. We present here four case reports of SLE cases with interesting hematological features. Our first case is a 13 month old female child who was initially diagnosed as Evans syndrome and 2 years later diagnosed as SLE. Second case is a 3 year old male child who had SLE with warm antibody AIHA. Third case is a 6 year old female child who presented with AIHA and was diagnosed with SLE 6 years later. Fourth case is a 6 year old female child diagnosed as SLE with aplastic anemia. Hematological findings should be carefully assessed and treated in order to decrease disease related morbidity.