Cost-Effectiveness of Drug-Coated Balloon Angioplasty versus Plain Old Balloon Angioplasty for Arteriovenous Fistula Stenosis.

OBJECTIVE: To compare the cost-effectiveness of drug-coated balloon angioplasty (DCB) versus plain old balloon angioplasty (POBA) for treatment of arteriovenous fistula (AVF) stenosis. METHODS: A Markov model was created to compare DCB versus POBA for AVF stenosis over a 2-year time horizon from a United States payer's perspective. Probabilities related to complications, restenosis, retreatment, and all-cause mortality were obtained from published literature. Costs were calculated using Medicare reimbursement rates and data from published cost analyses, inflation-adjusted to 2021. Health outcomes were measured with quality-adjusted life years (QALY). Probabilistic and deterministic sensitivity analyses were performed with a willingness-to-pay threshold of $100,000/QALY. RESULTS: Base case calculation showed better quality-of-life outcomes but increased cost with POBA compared to DCB, with an incremental cost-effectiveness ratio of $27,413/QALY, making POBA the more cost-effective strategy in the base case model. Sensitivity analyses showed that DCB becomes cost-effective if the 24-month mortality rate after DCB is no more than 3.4% higher than that after POBA. In secondary analyses where mortality rates were equalized, DCB was more cost-effective than POBA until its additional cost reached more than $4213 per intervention. CONCLUSION: When modeled from a payer's perspective over 2 years, the cost utility of DCB versus POBA varies with mortality outcomes. POBA is cost-effective if 2-year all-cause mortality after DCB is greater than 3.4% higher than after POBA. If 2-year mortality after DCB is less than 3.4% higher than after POBA, DCB is cost-effective until its additional cost per procedure exceeds $4213 more than POBA. LEVEL OF EVIDENCE IV: HISTORICALLY CONTROLLED STUDY.: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Geniculate Artery Embolization: Role in Knee Hemarthrosis and Osteoarthritis.

Roughly 37% of Americans 60 years of age and older experience chronic pain due to osteoarthritis (OA) of the knee. After conservative treatment (pharmacologic, physical therapy, and joint injections) fails, patients often require total knee arthroplasty to alleviate pain and regain knee function. Given the high economic burden of surgery paired with its invasive nature, many patients with this degenerative joint disease seek alternative treatment. Moreover, many patients with severe knee OA who also have comorbidities that preclude surgery-most often morbid obesity-are left without options. Geniculate artery embolization (GAE) is a minimally invasive intra-arterial intervention that was originally developed for the treatment of knee hemarthrosis that has recently been adapted for symptomatic knee OA. Through selective embolization of geniculate branches corresponding to the site of knee pain, GAE inhibits the neovascularity that contributes to the catabolic and inflammatory drive of OA. Preliminary trials over the past decade have demonstrated promising clinical results, including decreased pain and improved function and quality of life after treatment. Given such success, GAE provides another minimally invasive treatment option for knee OA to patients who feel reluctant to undergo or are ineligible for surgery. The authors review the radiographic manifestations and current standard of treatment of OA and hemarthrosis of the knee. Procedural technique, embolic selection, and clinical evidence for GAE in the treatment of OA and hemarthrosis of the knee are also explored. The online slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2021.

Performance of an expedited rhythm control method for recent onset atrial fibrillation in a community hospital.

BACKGROUND: A standard approach to recent onset atrial fibrillation (AF) in the emergency department (ED) in the United States has not been established. PURPOSE: The purpose of this prospective clinical trial was to determine how an ED protocol emphasizing rhythm control for recent onset AF compared similar patients receiving standard therapy in the same facility. METHODS: We enrolled consecutive patients presenting to our community hospital with recent onset AF into a protocol, which called for rhythm control with procainamide and if unsuccessful electrical cardioversion and discharge home. We compared this prospective cohort with matched historical controls. Primary outcome was admission rate. We also compared ED conversion rates and lengths of stay (LOS). We reported 30-day data on the study group including ED recidivism, recurrent AF, outpatient follow-up, and any important adverse events. RESULTS: Fifty-four patients were enrolled in the study group with 4 being admitted compared with 30 of 50 in the historical control group. Ninety-four percent of the study group converted compared with 28% in the historical control. Both hospital and ED LOS were significantly shorter for the study group. Six patients had recurrent AF, and 4 of those returned to the ED. CONCLUSION: An ED protocol that uses rhythm control decreased hospital admission and LOS, and there were no adverse events at 30 days.

The effect of IM droperidol on driving performance.

OBJECTIVES: Droperidol (DROP) is used in the emergency department (ED) for several indications, but its effect on psychomotor performance is unclear. The purpose of this study was to evaluate the effects of DROP, 2.5 mg intramuscular (IM), on driving performance. METHODS: This was a randomized, double-blinded, two-period, placebo-controlled crossover trial that utilized a standard driver-training program with computerized scoring. We solicited 20 paid volunteers who were pre-screened with a 12-lead EKG to evaluate QT length. For the first driving simulation, subjects were randomly assigned to receive either 2.5 mg of DROP IM or an equal volume of normal saline (NS). At least 72 hours later, the same subjects participated in a second driving simulation. For the second driving simulation, the assignment of DROP, 2.5 mg IM, or normal saline was reversed: (If a subject received DROP, 2.5 mg IM, in the first simulation, the subject received normal saline in the second simulation; conversely, if a subject received normal saline in the first simulation, the subject received DROP, 2.5 mg IM, in the second simulation). Thirty minutes later, participants drove the 20-minute simulation and received an average score based on the errors made in 4 categories: accelerating, braking, steering, and signaling. Post-testing, participants evaluated their degree of drowsiness and driving impairment using a visual analog scale and compared their perception of impairment to that caused by alcohol ingestion. Data were analyzed using analysis-of-variance, Pearson chi-square and Fischer's exact test with alpha set at p = 0.05. RESULTS: Twenty subjects (11 males and 9 females) completed the protocol. The mean age was 30 years with a range of 20 to 46 years, and the mean weight was 80 kg. The mean driving experience was 12 years. Participants who received DROP felt significantly drowsier (38.6 mm +/- 9.0) than those receiving NS (13.2 mm +/- 9.0), the mean difference was 25.4 mm p = .009. Subjects receiving DROP were also more likely to feel that their driving would be impaired as rated on the VAS (DROP: 34.6 +/- 5.2; NS: 3.2 +/- 5.2; p = .0005), and DROP subjects reported impairment equivalent to 1-4 drinks more frequently than those receiving placebo (61% vs. 16.7%, p < .001). These subjective feelings of impairment were confirmed by their driving performance on the simulator. The mean driving score, using the driving simulator, was 68.8% with DROP vs. 73.6% with NS; p = .013. CONCLUSIONS: Subjects receiving modest doses of IM DROP report increased perceptions of drowsiness, driving impairment, and intoxication; these perceptions are confirmed on objective testing.

Synchronized emergency department cardioversion of atrial dysrhythmias saves time, money and resources.

The strategy of elective synchronized cardioversion (EDCV) of new onset atrial fibrillation/flutter (AF/flutter) compares favorably to that of Emergency Department (ED) rate control and inpatient admission. This 1-year study comprised consecutive ED synchronized cardioversions performed on patients with new onset (< 48 h) AF/flutter; all were hemodynamically stable. A control group was obtained by chart review of all patients meeting the inclusion criteria admitted in the same year who were managed with rate control in the ED and inpatient admission. Thirty ED cardioversions were performed on 24 patients. Twenty-nine of 30 (97%) of ED cardioversions were successful. The mean hospital length of stay (LOS) for the EDCV group, including those admitted, was 22.8 h (95% CI: 1.7-44.0) compared to the control group: 55.6 h (all admitted) (95% CI: 41.6-69.6). Median LOS for the entire EDCV group was 4 h, compared with 39.3 h for the controls (p < 0.001). There was also a significant difference in median hospital charge, including ED care: EDCV group: $1598 vs. controls $4271 (p < 0.001). All of the study patients were contacted by telephone a minimum of 4 weeks after cardioversion to assess for complications, recidivism, and satisfaction. There were no complications in the EDCV group, and all expressed satisfaction with the procedure. Elective synchronized cardioversion in the ED is an effective strategy for management of new-onset AF/flutter and is associated with significant decreases in charges and length of stay as well as a high degree of patient satisfaction.

Preparing for chemical terrorism: stability of injectable atropine sulfate.

OBJECTIVE: A massive nerve agent attack may rapidly deplete in-date supplies of atropine. The authors considered using atropine beyond its labeled shelf life. The objective was to determine the stability of premixed injectable atropine sulfate samples with different expiration dates. METHODS: This was an in-vitro study using gas chromatography and mass spectrometry (GC/MS). Four atropine solutions (labeled concentration of 400 microg/mL) ranging from in date to 12 years beyond expiration (exp) and an additional sample of atropine sulfate (labeled concentration of 2,000 microg/mL) obtained from a World War II era autoinjector were assayed for atropine stability. Standards of atropine sulfate and tropine were prepared and quantified by GC/MS. Study samples were prepared by adding a buffer solution to free the base, extracting with an isopropanol/methylene chloride mixture and followed by evaporating the organic layer to dryness. Pentafluoropropionic anhydride and pentafluoropropanol were then added as derivatization reagents. Study samples were heated, the derivitization reagents were evaporated, and the remaining compound was reconstituted in ethyl acetate for injection into the GC/MS. RESULTS: All solutions were clear and colorless. Atropine concentrations were as follows: in date, 252 microg/mL; 2001 exp, 290 microg/mL; 1999 exp, 314 microg/mL; 1990 exp, 398 microg/mL; and WW II specimen, 1,475 microg/mL. Tropine was found in concentrations of <10 microg/mL in all study samples. CONCLUSIONS: Significant amounts of atropine were found in all study samples. All samples remained clear and colorless, and no substantial amount of tropine was found in any study sample. Further testing is needed to determine clinical effect.

Isolated case of bioterrorism-related inhalational anthrax, New York City, 2001.

On October 31, 2001, in New York City, a 61-year-old female hospital employee who had acquired inhalational anthrax died after a 6-day illness. To determine sources of exposure and identify additional persons at risk, the New York City Department of Health, Centers for Disease Control and Prevention, and law enforcement authorities conducted an extensive investigation, which included interviewing contacts, examining personal effects, summarizing patient's use of mass transit, conducting active case finding and surveillance near her residence and at her workplace, and collecting samples from co-workers and the environment. We cultured all specimens for Bacillus anthracis. We found no additional cases of cutaneous or inhalational anthrax. The route of exposure remains unknown. All environmental samples were negative for B. anthracis. This first case of inhalational anthrax during the 2001 outbreak with no apparent direct link to contaminated mail emphasizes the need for close coordination between public health and law enforcement agencies during bioterrorism-related investigations.

Laboratory response to anthrax bioterrorism, New York City, 2001.

In October 2001, the greater New York City Metropolitan Area was the scene of a bioterrorism attack. The scale of the public response to this attack was not foreseen and threatened to overwhelm the Bioterrorism Response Laboratory's (BTRL) ability to process and test environmental samples. In a joint effort with the Centers for Disease Control and Prevention and the cooperation of the Department of Defense, a massive effort was launched to maintain and sustain the laboratory response and return test results in a timely fashion. This effort was largely successful. The development and expansion of the facility are described, as are the special needs of a BTRL. The establishment of a Laboratory Bioterrorism Command Center and protocols for sample intake, processing, reporting, security, testing, staffing, and and quality control are also described.

Residency training in emergency ultrasound: fulfilling the mandate.

Although bedside ultrasound is listed in the Model of the Clinical Practice of Emergency Medicine as an integral diagnostic procedure, the manner in which the didactic, hands-on, and experiential components of emergency ultrasound are taught is not specifically prescribed by the Residency Review Committee for Emergency Medicine (RRC-EM) or any single sponsoring group. Seven professional organizations [the American Board of Emergency Medicine (ABEM), the American College of Emergency Medicine (ACEP), the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents Association (EMRA), the National Association of EMS Physicians (NAEMSP), the RRC-EM, and the Society for Academic Emergency Medicine (SAEM)] developed the Scope of Training Task Force, with the goal of identifying emerging areas of clinical importance to the specialty of emergency medicine, including emergency department (ED) ultrasound. The Task Force then identified a group of recognized authorities to thoughtfully address the issue of ED ultrasound training. This report represents a consensus of these identified experts on how emergency ultrasound training should be incorporated into emergency medicine residency programs.