Pre-hospital ECPR in an Australian metropolitan setting: a single-arm feasibility assessment-The CPR, pre-hospital ECPR and early reperfusion (CHEER3) study.

INTRODUCTION: Survival from refractory out of hospital cardiac arrest (OHCA) without timely return of spontaneous circulation (ROSC) utilising conventional advanced cardiac life support (ACLS) therapies is dismal. CHEER3 was a safety and feasibility study of pre-hospital deployed extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (ECPR) for refractory OHCA in metropolitan Australia. METHODS: This was a single jurisdiction, single-arm feasibility study. Physicians, with pre-existing ECMO expertise, responded to witnessed OHCA, age < 65 yrs, within 30 min driving-time, using an ECMO equipped rapid response vehicle. If pre-hospital ECPR was undertaken, patients were transported to hospital for investigations and therapies including emergent coronary catheterisation, and standard intensive care (ICU) therapy until either cardiac and neurological recovery or palliation occurred. Analyses were descriptive. RESULTS: From February 2020 to May 2023, over 117 days, the team responded to 709 "potential cardiac arrest" emergency calls. 358 were confirmed OHCA. Time from emergency call to scene arrival was 27 min (15-37 min). 10 patients fulfilled the pre-defined inclusion criteria and all were successfully cannulated on scene. Time from emergency call to ECMO initiation was 50 min (35-62 min). Time from decision to ECMO support was 16 min (11-26 min). CPR duration was 46 min (32-62 min). All 10 patients were transferred to hospital for investigations and therapy. 4 patients (40%) survived to hospital discharge neurologically intact (CPC 1/2). CONCLUSION: Pre-hospital ECPR was feasible, using an experienced ECMO team from a single-centre. Overall survival was promising in this highly selected group. Further prospective studies are now warranted.

Real-World Assessment of an Ultrathin Strut, Sirolimus-Eluting Stent in Patients with ST-Elevation Myocardial Infarction Submitted to Primary Percutaneous Coronary Intervention (INSTEMI Registry). / Avaliação no Mundo Real de um Stent Eluidor de Sirolimus de Hastes Ultrafinas em Pacientes com Infarto do Miocárdio com Supradesnivelamento do Segmento ST Submetidos à Intervenção Coronária Percutânea Primária (Registro INSTEMI).

BACKGROUND: The current gold standard of coronary drug-eluting stents (DES) consists of metal alloys with thinner struts and bioresorbable polymers. OBJECTIVES: Our aim was to compare an ultrathin strut, sirolimus-eluting stent (Inspiron®) with other third-generation DES platforms in patients with ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous coronary intervention (PCI). METHODS: We analyzed data from a STEMI multicenter registry from reference centers in the South Region of Brazil. All patients were submitted to primary PCI, either with Inspiron® or other second- or third-generation DES. Propensity score matching (PSM) was computed to generate similar groups (Inspiron® versus other stents) in relation to clinical and procedural characteristics. All hypothesis tests had a two-sided significance level of 0.05. RESULTS: From January 2017 to January 2021, 1711 patients underwent primary PCI, and 1417 patients met our entry criteria (709 patients in the Inspiron® group and 708 patients in the other second- or third-generation DES group). After PSM, the study sample was comprised of 706 patients (353 patients in the Inspiron® group and 353 patients in the other the other second- or third-generation DES group). The rates of target vessel revascularization (OR 0.52, CI 0.21 - 1.34, p = 0.173), stent thrombosis (OR 1.00, CI 0.29 - 3.48, p = 1.000), mortality (HR 0.724, CI 0.41 - 1.27, p = 0.257), and major cardiovascular outcomes (OR 1.170, CI 0.77 - 1.77, p = 0.526) were similar between groups after a median follow-up of 17 months. CONCLUSION: Our findings show that Inspiron® was effective and safe when compared to other second- or third-generation DES in a contemporary cohort of real-world STEMI patients submitted to primary PCI.

FUNDAMENTO: O padrão-ouro atual dos stents farmacológicos (SF) coronários consiste em ligas metálicas com hastes mais finas e polímeros bioabsorvíveis. OBJETIVOS: Nosso objetivo foi comparar um stent eluidor de sirolimus de hastes ultrafinas (Inspiron®) com outras plataformas de SF de terceira geração em pacientes com infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST) submetidos à intervenção coronária percutânea (ICP) primária. MÉTODOS: Analisamos dados de um registro multicêntrico de IAMCSST de centros de referência da Região Sul do Brasil. Todos os pacientes foram submetidos à ICP primária, seja com Inspiron® ou outro SF de segunda ou terceira geração. Foi calculado pareamento por escore de propensão (PEP) para gerar grupos semelhantes (Inspiron® versus outros stents) em relação às características clínicas e do procedimento. Todos os testes de hipótese tiveram um nível de significância bilateral de 0,05. RESULTADOS: De janeiro de 2017 a janeiro de 2021, 1.711 pacientes foram submetidos à ICP primária, e 1.417 pacientes preencheram nossos critérios de inclusão (709 pacientes no grupo Inspiron® e 708 pacientes no grupo dos outros SF de segunda ou terceira geração). Após PEP, a amostra do estudo foi composta por 706 pacientes (353 pacientes no grupo Inspiron® e 353 pacientes no grupo dos demais SF de segunda ou terceira geração). As taxas de revascularização do vaso alvo (odds ratio [OR] 0,52; intervalo de confiança [IC] 0,21 a 1,34; p = 0,173), trombose de stent (OR 1,00; IC 0,29 a 3,48;p = 1,000), mortalidade (hazard ratio 0,724; IC 0,41 a 1,27; p = 0,257) e os desfechos cardiovasculares maiores (OR 1,170; IC 0,77 a 1,77; p = 0,526) foram semelhantes entre os grupos após um acompanhamento mediano de 17 meses. CONCLUSÃO: Nossos achados mostram que o stent Inspiron® foi eficaz e seguro quando comparado a outros SF de segunda ou terceira geração em uma coorte contemporânea do mundo real de pacientes com IAMCSST submetidos à ICP primária.

Functional assessment based on cardiopulmonary exercise testing in mild heart failure: A multicentre study.

AIMS: In this multicentre study, we compared cardio-pulmonary exercise test (CPET) parameters between heart failure (HF) patients classified as New York Heart Association (NYHA) class I and II to assess NYHA performance and prognostic role in mild HF. METHODS AND RESULTS: We included consecutive HF patients in NYHA class I or II who underwent CPET in three Brazilian centres. We analysed the overlap between kernel density estimations for the per cent-predicted peak oxygen consumption (VO2 ), minute ventilation/carbon dioxide production (VE/VCO2 ) slope, and oxygen uptake efficiency slope (OUES) by NYHA class. Area under the receiver-operating characteristic curve (AUC) was used to assess the capacity of per cent-predicted peak VO2 to discriminate between NYHA class I and II. For prognostication, time to all-cause death was used to produce Kaplan-Meier estimates. Of 688 patients included in this study, 42% were classified as NYHA I and 58% as NYHA II, 55% were men, and mean age was 56 years. Median global per cent-predicted peak VO2 was 66.8% (IQR 56-80), VE/VCO2 slope was 36.9 (31.6-43.3), and mean OUES was 1.51 (±0.59). Kernel density overlap between NYHA class I and II was 86% for per cent-predicted peak VO2 , 89% for VE/VCO2 slope, and 84% for OUES. Receiving-operating curve analysis showed a significant, albeit limited performance of per cent-predicted peak VO2 alone to discriminate between NYHA class I vs. II (AUC 0.55, 95% CI 0.51-0.59, P = 0.005). Model accuracy for probability of being classified as NYHA class I (vs. NYHA class II) across the spectrum of the per cent-predicted peak VO2 was limited, with an absolute probability increment of 13% when per cent-predicted peak VO2 increased from 50% to 100%. Overall mortality in NYHA class I and II was not significantly different (P = 0.41), whereas NYHA class III patients displayed a distinctively higher death rate (P < 0.001). CONCLUSIONS: Patients with chronic HF classified as NYHA I overlapped substantially with those classified as NYHA II in objective physiological measures and prognosis. NYHA classification may represent a poor discriminator of cardiopulmonary capacity in patients with mild HF.

Avaliação no Mundo Real de um Stent Eluidor de Sirolimus de Hastes Ultrafinas em Pacientes com Infarto do Miocárdio com Supradesnivelamento do Segmento ST Submetidos à Intervenção Coronária Percutânea Primária (Registro INSTEMI) / Real-World Assessment of an Ultrathin Strut, Sirolimus-Eluting Stent in Patients with ST-Elevation Myocardial Infarction Submitted to Primary Percutaneous Coronary Intervention (INSTEMI Registry)

Resumo Fundamento O padrão-ouro atual dos stents farmacológicos (SF) coronários consiste em ligas metálicas com hastes mais finas e polímeros bioabsorvíveis. Objetivos Nosso objetivo foi comparar um stent eluidor de sirolimus de hastes ultrafinas (Inspiron®) com outras plataformas de SF de terceira geração em pacientes com infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST) submetidos à intervenção coronária percutânea (ICP) primária. Métodos Analisamos dados de um registro multicêntrico de IAMCSST de centros de referência da Região Sul do Brasil. Todos os pacientes foram submetidos à ICP primária, seja com Inspiron® ou outro SF de segunda ou terceira geração. Foi calculado pareamento por escore de propensão (PEP) para gerar grupos semelhantes (Inspiron® versus outros stents) em relação às características clínicas e do procedimento. Todos os testes de hipótese tiveram um nível de significância bilateral de 0,05. Resultados De janeiro de 2017 a janeiro de 2021, 1.711 pacientes foram submetidos à ICP primária, e 1.417 pacientes preencheram nossos critérios de inclusão (709 pacientes no grupo Inspiron® e 708 pacientes no grupo dos outros SF de segunda ou terceira geração). Após PEP, a amostra do estudo foi composta por 706 pacientes (353 pacientes no grupo Inspiron® e 353 pacientes no grupo dos demais SF de segunda ou terceira geração). As taxas de revascularização do vaso alvo (odds ratio [OR] 0,52; intervalo de confiança [IC] 0,21 a 1,34; p = 0,173), trombose de stent (OR 1,00; IC 0,29 a 3,48;p = 1,000), mortalidade (hazard ratio 0,724; IC 0,41 a 1,27; p = 0,257) e os desfechos cardiovasculares maiores (OR 1,170; IC 0,77 a 1,77; p = 0,526) foram semelhantes entre os grupos após um acompanhamento mediano de 17 meses. Conclusão Nossos achados mostram que o stent Inspiron® foi eficaz e seguro quando comparado a outros SF de segunda ou terceira geração em uma coorte contemporânea do mundo real de pacientes com IAMCSST submetidos à ICP primária.

Abstract Background The current gold standard of coronary drug-eluting stents (DES) consists of metal alloys with thinner struts and bioresorbable polymers. Objectives Our aim was to compare an ultrathin strut, sirolimus-eluting stent (Inspiron®) with other third-generation DES platforms in patients with ST-elevation myocardial infarction (STEMI) submitted to primary percutaneous coronary intervention (PCI). Methods We analyzed data from a STEMI multicenter registry from reference centers in the South Region of Brazil. All patients were submitted to primary PCI, either with Inspiron® or other second- or third-generation DES. Propensity score matching (PSM) was computed to generate similar groups (Inspiron® versus other stents) in relation to clinical and procedural characteristics. All hypothesis tests had a two-sided significance level of 0.05. Results From January 2017 to January 2021, 1711 patients underwent primary PCI, and 1417 patients met our entry criteria (709 patients in the Inspiron® group and 708 patients in the other second- or third-generation DES group). After PSM, the study sample was comprised of 706 patients (353 patients in the Inspiron® group and 353 patients in the other the other second- or third-generation DES group). The rates of target vessel revascularization (OR 0.52, CI 0.21 - 1.34, p = 0.173), stent thrombosis (OR 1.00, CI 0.29 - 3.48, p = 1.000), mortality (HR 0.724, CI 0.41 - 1.27, p = 0.257), and major cardiovascular outcomes (OR 1.170, CI 0.77 - 1.77, p = 0.526) were similar between groups after a median follow-up of 17 months. Conclusion Our findings show that Inspiron® was effective and safe when compared to other second- or third-generation DES in a contemporary cohort of real-world STEMI patients submitted to primary PCI.

The Impact of the Affordable Care Act on Outpatient Spine Trauma Consult Follow-up.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The objective of this study was to assess the impact of the Affordable Care Act (ACA) on spine trauma patient follow-up. SUMMARY OF BACKGROUND DATA: Although damage to the spinal column accounts for a small proportion of all traumatic injuries, it results in a significant burden on the patient, provider, and health care system. Postoperative follow-up is essential to direct rehabilitation, prevent early deterioration, and manage complications early in the postoperative period. Previous studies have established the role of insurance coverage on follow-up compliance, however, the impact of the ACA on follow-up has been scant. MATERIALS AND METHODS: A retrospective cohort study was performed upon institutional review board approval of spine trauma patients consulted by orthopedic spine or neurosurgery from January 2013 to December 2013 (pre-ACA) and January 2015 to December 2015 (post-ACA). Patient demographics, surgical case characteristics, and follow-up compliance were assessed via manual chart review. Multivariate regression analysis was used to identify predictors of follow-up in the overall cohort, as well as within nonoperative and operative patients. RESULTS: A total of 827 patients were included in the final analysis after inclusion and exclusion criteria. Overall, patient follow-up significantly increased after implementation of the ACA (P<0.001), with pre-ACA follow-up at 35.0% (144/411) and post-ACA follow-up at 50.0% (208/516). Multivariate regression analysis further corroborated these findings, showing post-ACA status associated with a 1.66-fold higher likelihood of follow-up. Among nonoperative patients, the ACA failed to make a significant difference in follow-up (P=0.56), however, patients treated operatively showed a significantly higher likelihood of follow-up (odds ratio=2.92, P<0.001). CONCLUSIONS: Postoperative follow-up is an essential part of patient care, aiding in improving clinical outcomes and limiting the economic burden on the health care system. This study suggests that passage of the ACA significantly improved patient follow-up for operatively managed patients but not for nonoperatively managed patients. LEVEL OF EVIDENCE: Level III.

Impact of the Affordable Care Act on Insurance Status of Spine Patients Presenting to the Emergency Department.

Although the Affordable Care Act (ACA) has been shown to broadly affect access to care, there is little data examining the change in insurance status with regard to nonelective spinal trauma, infection, and tumor patients. The purpose of this study is to evaluate the changes in insurance status before and after implementation of the ACA in patients who present to the emergency room of a single, level 1 trauma and regional spinal cord injury center. Patient demographic and hospital course information were derived from consult notes and electronic medical record review. Spinal consults between January 1, 2013, and December 31, 2015, were initially included. Consults between January 1 and December 31, 2014, were subsequently removed to obtain two separate cohorts reflecting one calendar year prior to ("pre-ACA") and following ("post-ACA") the effective date of implementation of the ACA on January 1, 2014. Compared with the pre-ACA cohort, the post-ACA cohort had a significant increase in insurance coverage (95.0% versus 83.9%, P < 0.001). Post-ACA consults had a significantly shorter length of stay compared with pre-ACA consults (7.94 versus 9.19, P < 0.001). A significantly greater percentage of the post-ACA cohort appeared for clinical follow-up subsequent to their initial consultation compared to the pre-ACA cohort (49.5% versus 35.3%, P < 0.001). Spinal consultation after the implementation of the ACA was found to be a significant positive predictor of Medicaid coverage (odds ratio = 1.96 [1.05, 3.82], P = 0.04) and a significant negative predictor of uninsured status (odds ratio = 0.28 [0.16, 0.47], P < 0.001). Increase in overall insurance coverage, increase in patient follow-up after initial consultation, and decrease in hospital length of stay were all noted after the implementation of the ACA for spinal consultation patients presenting to the emergency department.

Reimbursement of Lumbar Decompression at an Orthopedic Specialty Hospital Versus Tertiary Referral Center.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to investigate the differences in Medicare reimbursement for one- to three-level lumbar decompression procedures performed at a tertiary referral center versus an orthopedic specialty hospital (OSH). SUMMARY OF BACKGROUND DATA: Lumbar decompression surgery is one of the most commonly performed spinal procedures. Lumbar decompression also comprises the largest proportion of spinal surgery that has transitioned to the outpatient setting. METHODS: Patients who underwent a primary one- to three- level lumbar decompression were retrospectively identified. Reimbursement data for a tertiary referral center and an OSH were compiled through Centers for Medicare and Medicaid Services. Demographic data, surgical characteristics, and time cost data were collected through chart review. Multivariate regression models were used to determine independent factors associated with total episode of care cost, operating room (OR) time, procedure time, and length of stay (LOS), and to determine independent predictors of having the decompression performed at the OSH. RESULTS: Total episode of care, facility, and non-facility payments were significantly greater at the tertiary referral center than the OSH, as were OR time for one- to three-level procedures, procedure time of all pooled levels, and LOS for one- and two-level procedures. Three-level procedure was independently associated with increased OR time, procedure time, and LOS. Age and two-level procedure were also associated with increased LOS. Procedure at the OSH was associated with decreased OR time and LOS. Charlson Comorbidity Index was a negative predictor of decompression being performed in the OSH setting. CONCLUSION: Significant financial savings to health systems can be expected when performing lumbar decompression surgery at a specialty hospital as opposed to a tertiary referral center. Patients who are appropriate candidates for surgery in an OSH can in turn expect faster perioperative times and shorter LOS.Level of Evidence: 3.

Medicaid Reimbursement for Common Spine Procedures: Are Compensation Rates Consistent?

STUDY DESIGN: Health Services Research. OBJECTIVE: The purpose of this study is to determine the variability of Medicaid (MCD) reimbursement for patients who require spine procedures, and to assess how this compares to regional Medicare (MCR) reimbursement as a marker of access to spine surgery. SUMMARY OF BACKGROUND DATA: The current health care environment includes two major forms of government reimbursement: MCD and MCR, which are regulated and funded by the state and federal government, respectively. METHODS: MCD reimbursement rates from each state were obtained for eight spine procedures, utilizing online web searches: anterior cervical decompression and fusion, posterior cervical decompression and fusion, posterior lumbar decompression, single-level posterior lumbar fusion, posterior fusion for deformity (less than six levels; six to 12 levels; 13+ levels), and lumbar microdiscectomy. Discrepancy in reimbursement for these procedures on a state-to-state basis, as well as overall differences in MCD versus MCR reimbursement, was determined. Procedures were examined to identify whether certain surgical interventions have greater discrepancy in reimbursement. RESULTS: The average MCD reimbursement was 78.4% of that for MCR. However, there was significant variation between states (38.8%-140% of MCR for the combined eight procedures). On average, New York, New Jersey, Florida, and Rhode Island provided MCD reimbursements <50% of MCR reimbursements in the region. In total, 20 and 42 states provided <75% and 100% of MCR reimbursements, respectively. Based upon relative reimbursement, MCD appears to value microdiscectomy (84.1% of MCR; P = 0.10) over other elective spine procedures. Microdiscectomy also had the most interstate variation in MCD reimbursement: 39.0% to 207.0% of MCR. CONCLUSION: Large disparities were found between MCR and MCD when comparing identical procedures. Further research is necessary to fully understand the effect of these significant differences. However, it is likely that these discrepancies lead to suboptimal access to necessary spine care. LEVEL OF EVIDENCE: 4.

Medicaid Reimbursement for Common Orthopedic Procedures Is Not Consistent.

Two major forms of physician reimbursement include Medicare (MCR; federally funded) and Medicaid (MCD; state funded). The only oversight provided to individual states for setting MCD reimbursement is that it must provide a standard payment that does not negatively affect patient care. The goals of this study were to determine the variability of MCD reimbursement for patients who require orthopedic procedures and to assess how this compares with regional MCR reimbursement. Medicaid reimbursement rates from each state were obtained for total knee arthroplasty, total hip arthroplasty, anterior cruciate ligament repair, rotator cuff repair, anterior cervical decompression and fusion, posterior lumbar decompression, carpal tunnel release, distal radius open reduction and internal fixation, proximal femur open reduction and internal fixation, and ankle open reduction and internal fixation. Discrepancy in reimbursement for these procedures and overall differences in MCD vs MCR reimbursement were determined. Average MCD reimbursement was 81.9% of MCR reimbursement. There was significant variation between states (37.7% to 147% of MCR reimbursement for all 10 procedures). Twenty and 40 states provided less than 75% and 100% of MCR reimbursements, respectively. Medicaid valued knee arthroplasty (91.4% of MCR reimbursement) over other common procedures. Conversely, carpal tunnel release (74.1% of MCR reimbursement; P=.004) had the lowest reimbursements. The most interstate variation was noted for anterior cruciate ligament reimbursement, ranging from 20.6% to 229% of local MCR reimbursement. Disparities were found between MCR and MCD when comparing identical procedures. Further research is necessary to understand the impact of these significant differences. It is likely that these discrepancies lead to suboptimal access to necessary orthopedic care. [Orthopedics. 2019; 42(2):e193-e196.].

Cost-based optimization of the stopping threshold for local disease surveillance during progressive eradication of tuberculosis from New Zealand wildlife.

Bovine tuberculosis (TB) is managed in New Zealand largely via population reduction of the major wildlife disease reservoir of Mycobacterium bovis, the introduced brushtail possum Trichosurus vulpecula. New Zealand aims to eradicate M. bovis infection from its livestock and wildlife within 40 years, as the culmination of progressive regional eradication programmes. Declarations of regional eradication are decided after extensive possum population control and post-control surveillance; hence, we developed a modelling framework, based on eco-epidemiological simulation data, to provide cost-evaluated options for deciding when to make these declarations. A decision-support framework evaluated potential costs of wildlife surveillance (and recontrol, if required) with respect to the calculated probability of successful eradication of M. bovis from wildlife. This enabled expected costs to be predicted in terms of stopping thresholds, allowing selection of optimal stopping rules based on minimizing costs. We identified factors that could influence optimal stopping values applied during regional eradication. Where vector/disease surveillance was inexpensive (for example, using low-cost detection devices or sentinel wildlife hosts) optimization involved setting a higher rather than lower stopping value, as it would be cheaper to minimize the risk of making a false declaration of eradication than to remedy any such failure. In addition, any cost of recontrol would largely depend on the time to rediscovery of residual M. bovis infection in wildlife, which would in turn be linked to the level of ongoing passive surveillance (with more rapid detection of re-emergent infection among wildlife in farmland situations than in remote forested regions). These two scenarios would favour different optimal stopping rules, as would the consideration of stakeholder confidence and socio-political issues, which are discussed. The framework presented here provides guidance to assess the economics underlying eradication of bovine TB from New Zealand farming; this eliminates reliance upon a pre-determined and uniform stopping rule for ceasing active management.

The Effect of Hospital Ownership on Health Care Utilization in Orthopedic Surgery.

PURPOSE: To determine if ownership of a specialty hospital or ambulatory surgery centers (ASC) affects surgical volume. MATERIALS AND METHODS: All surgeries performed by 75 orthopedic surgeons at a single practice between January 1, 2010 and March 1, 2015 were identified. During this time, the practice purchased an ownership stake in 1 hospital and 3 ASC. The total surgical volume by partnership status and location was collected and analyzed. RESULTS: A total of 104,661 surgical surgeries were performed by 75 surgeons. Over the 62 months, there was an average increase in the number of surgical cases performed per surgeon per year of 2.82±0.48 cases; however, the average increase in cases per year was lower for equity partners by 1.51 cases per year (P<0.0001). In the 2 years before purchasing the specialty hospital, the increase in the number of surgical cases per surgeon per month was 0.093±0.087 cases. In the 2 years after investing in the physician-owned specialty hospital, there was a decrease in the number of cases performed per surgeon per month by 0.027±0.110 (P=0.92). CONCLUSIONS: In a well-established large orthopedic practice, surgeon ownership of a hospital or ASC does not lead to an increase in surgical volume. LEVEL OF EVIDENCE: Level 4.

[Cost effectiveness of GnRH antagonists in patients with prostate cancer and cardiovascular risk : Comparative analysis against Leuprorelin by the Number Needed to Treat]. / Kosteneffektivität von GnRH-Antagonisten bei Patienten mit Prostatakarzinom und kardiovaskulärem Risiko : Vergleichende Analyse gegenüber Leuprorelin anhand der Number Needed to Treat.

BACKGROUND: Recent studies suggest that androgen deprivation therapy (ADT) is associated with increased cardiovascular (CV) risk for patients with hormone-sensitive prostate cancer (PCa) and pre-existing CV disease. This risk seems to be different for the gonadotropin-releasing hormone (GnRH) agonists leuprolide and goserelin and GnRH antagonists, whereas the slightly more expensive GnRH antagonist shows a beneficial risk profile. The present study assesses the cost effectiveness of degarelix compared to leuprolide for PCa patients with increased CV risk. METHODS: This analysis is based on a pooled analysis of six phase III, randomized, controlled trials comparing the GnRH agonists leuprolide and goserelin with the GnRH antagonist degarelix. For the combined endpoint of CV events or death a superiority of degarelix was determined with a Number-Needed-to-Treat of 12. From the perspective of German statutory health insurance, this evaluation estimates and compares the additional drug costs of degarelix treatment to the cost of one (avoided) CV event. The CV event costs were estimated via emergency treatment and transportation, inpatient treatment, and rehabilitation. The difference of these two cost pools divided by 12 yields the average saving per patient and year. RESULTS: For every 12 PCa patients with CV history that are treated with GnRH antagonists to prevent one CV event, there will be additional drug costs in comparison with leuprolide treatment of € 3111 per year. Costs of € 8447 per year are prevented. Therefore, each patient with a history of CV who is treated with degarelix instead of a leuprolide generates savings of € 445 per patient and year. CONCLUSIONS: Compared to leuprolide, degarelix is cost effective for patients with increased CV risk.

The Economic Implications of an Incidental Durotomy.

STUDY DESIGN: Case-control. OBJECTIVE: The aim of this study was to determine the economic impact of an incidental durotomy in spine surgery. SUMMARY OF BACKGROUND DATA: An incidental durotomy during spine surgery does not affect long-term outcomes, but as reimbursement moves toward bundled payments, it may substantially affect the profitability of spine surgery. METHODS: A retrospective review of a prospectively collected morbidity and mortality database identified all patients with an incidental durotomy between January 1, 2012, and January 11, 2013. Subjects with a dural tear were matched to controls (1 : 2) without a dural tear, and the total charges for one year were collected. Controls were required to meet the following criteria: Age ±5 years; Charlson Comorbidity Index (CCI) ±1; Date of surgery ±2 years; Exact region of the spine, but not the exact level (i.e., lumbar → lumbar); Exact type of fusion (i.e., approach, instrumentation); Exact number of levels fused; Use of rhBMP-2; Number of levels decompressed ±1. RESULTS: Two controls without a dural tear could be identified for 57 patients who sustained an incidental durotomy. No difference in demographic data, emergency room visits, hospital readmissions, or revision surgeries between the groups was identified. Patients with an incidental durotomy had a longer operative time by 30.6 ±â€Š8.5 minutes (P < 0.01), longer length of stay by 0.89 ±â€Š0.27 days (P = 0.0001), and an increase in their average initial hospital charge by 18%. No increase in surgeon-based charges or hospital-based charges after the initial visit was identified. CONCLUSION: An incidental durotomy significantly increases the initial hospital charges for patients undergoing spine surgery; however, in this study it has no effect on surgeon-based charges or on hospital-based charges after discharge. LEVEL OF EVIDENCE: 3.

The Meth Project and Teen Meth Use: New Estimates from the National and State Youth Risk Behavior Surveys.

In this note, we use data from the national and state Youth Risk Behavior Surveys for the period 1999 through 2011 to estimate the relationship between the Meth Project, an anti-methamphetamine advertising campaign, and meth use among high school students. During this period, a total of eight states adopted anti-meth advertising campaigns. After accounting for pre-existing downward trends in meth use, we find little evidence that the campaign curbed meth use in the full sample. We do find, however, some evidence that the Meth Project may have decreased meth use among White high school students.

A semi-automated method for bone age assessment using cervical vertebral maturation.

OBJECTIVE: To propose a semi-automated method for pattern classification to predict individuals' stage of growth based on morphologic characteristics that are described in the modified cervical vertebral maturation (CVM) method of Baccetti et al. MATERIALS AND METHODS: A total of 188 lateral cephalograms were collected, digitized, evaluated manually, and grouped into cervical stages by two expert examiners. Landmarks were located on each image and measured. Three pattern classifiers based on the Naïve Bayes algorithm were built and assessed using a software program. The classifier with the greatest accuracy according to the weighted kappa test was considered best. RESULTS: The classifier showed a weighted kappa coefficient of 0.861 ± 0.020. If an adjacent estimated pre-stage or poststage value was taken to be acceptable, the classifier would show a weighted kappa coefficient of 0.992 ± 0.019. CONCLUSION: Results from this study show that the proposed semi-automated pattern classification method can help orthodontists identify the stage of CVM. However, additional studies are needed before this semi-automated classification method for CVM assessment can be implemented in clinical practice.

Younger and older women's concerns about menopause after breast cancer.

A number of treatments for breast cancer induce menopause. This study's aim was to explore women's perceptions and beliefs about menopausal symptoms and their management following breast cancer, and to compare younger and older women's experiences. Data were collected via semi-structured focus groups from women who had undergone treatment for breast cancer, and who were currently experiencing menopausal symptoms. Data were interpreted by way of simple inductive thematic analysis. The women experienced a range of menopausal symptoms that they were not prepared for and found difficult to manage. The central themes related to their lack of knowledge of how to manage menopausal symptoms, and the distress and helplessness that arose from this. Women who were diagnosed prior to 40 years of age reported additional menopausal issues than women who were older at diagnosis. The women in this study expressed a thirst for information related to menopause after breast cancer. The women identified that their needs with regard to menopause after breast cancer were not being met, either through their own lack of knowledge or via conflicting or absent support and management. The importance of enabling women to deal with menopausal symptoms was a central theme to emerge from the data.

Preliminary assessment of Treponema pallidum-specific IgM antibody detection and a new rapid point-of-care assay for the diagnosis of syphilis in human immunodeficiency virus-1-infected patients.

The aims of the study were to assess whether Treponema pallidum-specific IgM may provide a useful marker of infectious syphilis in human immunodeficiency virus (HIV)-infected patients, and to compare the performance of a prototype IgM-rapid point-of-care test (PoCT) with a standard IgM-enzyme immunoassay (EIA). Twenty samples from HIV-infected patients with untreated syphilis (n = 4 primary syphilis, n = 11 secondary and n = 5 early latent) and 51 follow-up samples at three, six or 12 months after treatment were tested for the presence of IgM with the Mercia-EIA (Microgen Bioproducts Ltd, Camberley, UK) and a prototype PoCT (Select Vaccines Ltd, Melbourne, Australia). Although sample numbers were small, IgM detection by EIA appears to be a reliable marker for untreated syphilis in HIV-infected patients with primary (4/4 IgM-positive) or secondary syphilis (10/11 IgM-positive, 1/11 equivocal). After treatment, IgM was no longer detected after three months in the majority of patients (87%) and was either negative or equivocal in all patients after six and 12 months. The overall sensitivity of the IgM-PoCT was 82% and varied with clinical stage, being highest in secondary (10/10 EIA positives) but lower in primary (2/4 EIA positives) and early latent syphilis (2/3 EIA positives). Overall specificity was 95%. Rapid detection of IgM would enable clinicians to distinguish between past-treated and infectious syphilis and allow for diagnosis and treatment in a single visit.