Economic analysis of emerald ash borer (Coleoptera: Buprestidae) management options.

Emerald ash borer, Agrilus planipennis (Fairmaire) (Coleoptera: Buprestidae), plays a significant role in the health and extent of management of native North American ash species in urban forests. An economic analysis of management options was performed to aid decision makers in preparing for likely future infestations. Separate ash tree population valuations were derived from the i-Tree Streets program and the Council of Tree and Landscape Appraisers (CTLA) methodology. A relative economic analysis was used to compare a control option (do-nothing approach, only removing ash trees as they die) to three distinct management options: 1) preemptive removal of all ash trees over a 5 yr period, 2) preemptive removal of all ash trees and replacement with comparable nonash trees, or 3) treating the entire population of ash trees with insecticides to minimize mortality. For each valuation and management option, an annual analysis was performed for both the remaining ash tree population and those lost to emerald ash borer. Retention of ash trees using insecticide treatments typically retained greater urban forest value, followed by doing nothing (control), which was better than preemptive removal and replacement. Preemptive removal without tree replacement, which was the least expensive management option, also provided the lowest net urban forest value over the 20-yr simulation. A "no emerald ash borer" scenario was modeled to further serve as a benchmark for each management option and provide a level of economic justification for regulatory programs aimed at slowing the movement of emerald ash borer.

Image quality assessment of the right ventricle with three different delayed enhancement sequences in patients suspected of ARVC/D.

Histopathologic findings in arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) are replacement of the normal myocardium with fatty and fibrous elements with preferential involvement of the right ventricle. The right ventricular fibrosis can be visualised by post-gadolinium delayed enhancement inversion recovery imaging (DE imaging). We compared the image quality of three different gradient echo MRI sequences for short axis DE imaging of the right ventricle (RV). We retrospectively analysed MRI scans performed between February 2005 and December 2008 in 97 patients (mean age: 41.2 years, 67% men) suspected of ARVC/D. For DE imaging either a 2D Phase Sensitive (PSIR), a 2D (2D) or a 3D (3D) inversion recovery sequence was used in respectively 38, 32 and 27 MRI-examinations. The RV, divided in 10 segments, was assessed for image quality by two radiologists in random sequence. A consensus reading was performed if results differed between the two readings. Image quality was good in 24% of all segments in the 3D group, 66% in the 2D group and 79% in the PSIR group. Poor image quality was observed in 51% (3D), 10% (2D), and 2% (PSIR) of all segments. Exams were considered suitable for clinical use in 7% of exams in the 3D group, 75% of exams in the 2D group and 90% of exams of the PSIR group. Breathing-artifacts occurred in 22% (3D), 59% (2D) and 53% (PSIR). Motion-artifacts occurred in 56% (3D), 28% (2D) and 29% (PSIR). Post-gadolinium imaging using the PSIR sequence results in better and more consistent image quality of the RV compared to the 2D and 3D sequences.

A 12-month quality of life assessment of cardiac arrest survivors treated with or without an implantable cardioverter defibrillator.

BACKGROUND: Previous studies indicate that the implantable cardioverter defibrillator (ICD) has a large impact on the quality of life of patients. The effects of having an ICD over longer periods of times has been less studied. OBJECTIVE: To assess the quality of life and well-being of cardiac arrest survivors who have received an implantable cardioverter defibrillator (ICD) or other treatment. METHODS: 168 patients were monitored for 1 year and completed four questionnaires. RESULTS: No differences were found between the two treatments regarding quality of life (except for pain, ICD patients perceived less pain) and well-being. A significant improvement in physical and social function, and in mental health was found in the first 6 months. Older patients (60 years or older) perceived less improvement in their health than younger patients. Women reported having poorer social function. The prevalence of anxiety and probable depression was high irrespective of the treatment received: anxiety and depressive symptoms did not change significantly between 1 and 12 months after discharge. Patients with higher anxiety scores experienced less improvement in health and patients with more depressive symptoms experienced poorer social function. CONCLUSIONS: The prevalence of anxiety and probable depression was high in cardiac arrest survivors. Probable depression affected social function. Those patients who felt anxious experienced less health improvement. Quality of life and well-being were not affected by the type of treatment. We conclude that surviving an out-of-hospital cardiac arrest has a greater impact on patients than the treatment received.

[Imaging diagnosis in suspected inflammatory rheumatoid axial skeleton diseases (sacroilitis)]. / Bildgebende Diagnostik bei Verdacht auf entzündlich rheumatische Achsenskeletterkrankungen (Sakroiliitis).

Involvement of the sacroiliac joints is a hallmark of the spondyloarthropathies, especially in ankylosing spondylitis. The conventional diagnostic imaging of sacroiliitis in early stages might cause problems, because sensitivity of conventional radiographic methods is known to be too low in early stages of the disease. Magnetic resonance imaging of the sacroiliac joints certainly enables one to detect acute as well as chronic inflammatory changes in all stages of the disease. The potential disadvantages of this method are the dependency on the examiner, the lack of standardization, and the relatively high costs. Therefore, the "Workgroup of Diagnostic Imaging in Rheumatology of the Regional Center of Rheumatology of Berlin" including experienced rheumatologists, skeletal radiologists, and orthopedists acquired an imaging graduation for detection of sacroiliitis in consideration of the clinical background, the technical details of the methods, questions of ionizing radiation exposure, and cost effectiveness.

Can implantable cardioverter-defibrillator therapy reduce healthcare costs?

This article presents a comparison of the costs and the cost effectiveness of defibrillator implantation in a hypothetical scenario for the years 1996-2000, with recently reported actual data from the Dutch prospective study over the years 1989-1993. Recently, technological advances in pulse generator and leads have revolutionized implantable cardioverter-defibrillator (ICD) therapy. Major advances include (1) transvenous single lead positioning and (2) tremendously reduced size, combined with prolonged longevity of the pulse generator. Both have simplified implantation technique and provided for superior effectiveness and lower costs. This suggests that a more favorable cost-effectiveness is to be expected. The study group reported here consisted of patients successfully resuscitated after cardiac arrest due to malignant ventricular tachyarrhythmias in the chronic stage of myocardial infarction. During a mean follow-up of 27 months, starting on the day of therapeutic decision making, total costs and the cost-effectiveness ratio were estimated. Actual data from the prospective study in 1989-1993 are compared with a hypothetical scenario for 1996-2000. Mortality and costs for hospitalization per day, per procedure, and per device are taken from the prospective study and equalized for both scenarios. Transthoracic lead positioning and abdominal implantation of a Ventak P (CPI) defibrillator with +/- 3 years longevity were characteristic of the recently completed prospective study. The hypothetical future scenario uses the Ventak Mini-2 with assumed 5 years longevity, implanted pectorally and connected to a single transvenous lead. Implantation will be carried out in the catheterization laboratory and as first-choice treatment. Due to prolonged longevity of the device and shorter hospitalization, a cost reduction of US $11,530 per patient is expected. Total costs per patient in the 1989-1993 prospective study in the (1) conventional arm (drugs first choice), (2) early ICD arm (ICD first choice), and (3) early ICD arm in the 1996-2000 study (ICD first choice) are $63,032, $56,067, and $44,537, respectively. The corresponding cost-effectiveness ratios are $87, $64, and $51 per day alive, respectively. Thus, it appears that modem ICD technology will be associated with an increasing reduction in healthcare costs, at least in selected patients. This reduction is associated with a more favorable cost-effectiveness ratio.

Cost-effectiveness of implantable defibrillator as first-choice therapy versus electrophysiologically guided, tiered strategy in postinfarct sudden death survivors. A randomized study.

BACKGROUND: Rising costs of health care, partly as a result of costly therapeutic innovations, are of concern to both the medical profession and healthcare authorities. The implantable cardioverter-defibrillator (ICD) is still not remunerated by Dutch healthcare insurers. The aim of this study was to evaluate the cost-effectiveness of early implantation of the ICD in postinfarct sudden death survivors. METHODS AND RESULTS: Sixty consecutive postinfarct survivors of cardiac arrest caused by ventricular tachycardia or fibrillation were randomly assigned either ICD as first choice (n = 29) or a tiered therapy starting with antiarrhythmic drugs and guided by electrophysiological (EP) testing (n = 31). Median follow-up was 729 days (range, 3 to 1675 days). Fifteen patients died, 4 in the early ICD group and 11 in the EP-guided strategy group (P = .07). For quantitative assessment, the cost-effectiveness ratio was calculated for both groups and expressed as median total costs per patient per day alive. Because effectiveness aspects other than mortality are not incorporated in this ratio, other factors related to quality of life were used as qualitative measures of cost-effectiveness. The cost-effectiveness ratios were $63 and $94 for the early ICD and EP-guided strategy groups, respectively, per patient per day alive. This amounts to a net cost-effectiveness of $11,315 per patient per year alive saved by early ICD implantation. Costs in the early ICD group were higher only during the first 3 months of follow-up, but as a result of the high proportion of therapy changes, including arrhythmia surgery and late ICD implantation, costs in the EP-guided strategy group became higher after that. Patients discharged with antiarrhythmic drugs as sole therapy had the lowest total costs. This subset, however, showed extremely high mortality, resulting in a poor cost-effectiveness ratio ($196 per day). Invasive therapies and hospitalization were the major contributors to costs. If quality-of-life measures are taken into account, the cost-effectiveness of early ICD implantation was even more favorable. Recurrent cardiac arrest and cardiac transplantation occurred in the EP-guided strategy group only, whereas exercise tolerance, total hospitalization duration, number of invasive procedures, and antiarrhythmic therapy changes were significantly in favor of early ICD implantation. CONCLUSIONS: In terms of cost-effectiveness, early ICD implantation is superior to the EP-guided therapeutic strategy in postinfarct sudden death survivors.

Automatic implantable cardioverter defibrillator: cost effectiveness.

Unexpected out-of-hospital cardiac arrest is in most cases due to ventricular fibrillation or rapid ventricular tachycardia. The usual therapeutic strategy in survivors starts with drug treatment, in case of failure followed by nonpharmacological therapy, which may include catheter ablation, ablative surgery, and finally defibrillator implantation. In most cases, this strategy is long lasting and very expensive. Implantation of a defibrillator as a first choice therapy may be cost effective, especially if the probability of successful drug treatment is low. However, cost-effective aspects have been studied only retrospectively and in models. In 1989 we started a prospective cost-effectiveness analysis of implantation of the automatic implantable cardioverter defibrillator (AICD) as first choice therapy ("early" AICD implantation) in successfully resuscitated postinfarct patients. Evaluation is being done in a randomized way with one group having early AICD implantation and the other group following the usual conventional therapeutic strategy. We compare medical, economic, and quality-of-life aspects. As of June 1992, 46 patients have entered the study. Totally 60 patients will be included. Results are expected in 1993 and will be expressed as cost effectiveness ratios in both study arms.