Implementation of Bundled Payment Initiatives for Total Joint Arthroplasty: Decreasing Cost and Increasing Quality.

Although the Bundled Payments for Care Improvement (BPCI) Initiative began generating data in January 2013, it may be years before the data can determine if the BPCI Initiative enhances value without decreasing quality. Private insurers have implemented other bundled payment arrangements for the delivery of total joint arthroplasty in a variety of practice settings. It is important for surgeons to review the early results of the BPCI Initiative and other bundled payment arrangements to understand the challenges and benefits of healthcare delivery systems with respect to total joint arthroplasty. In addition, surgeons should understand methods of cost control and quality improvement to determine the effect of the BPCI Initiative on the value-quality equation with respect to total joint arthroplasty.

Risk-Stratified Venous Thromboembolism Prophylaxis After Total Joint Arthroplasty: Aspirin and Sequential Pneumatic Compression Devices vs Aggressive Chemoprophylaxis.

BACKGROUND: Venous thromboembolism (VTE) is a major concern after total joint arthroplasty (TJA). We evaluated a risk-stratified prophylaxis protocol for patients undergoing TJA. METHODS: A total of 2611 TJA patients were retrospectively studied. Patients treated with an aggressive VTE chemoprophylaxis protocol were compared with patients treated with a risk-stratified protocol utilizing aspirin and sequential pneumatic compression devices (SPCDs) for standard-risk patients and targeted anticoagulation for high-risk patients. RESULTS: We found equivalence in terms of VTE prevention between the 2 cohorts. There was a decrease in adverse events and readmissions among the risk-stratified cohort, although this did not reach statistical significance. A statistically significant reduction in costs (P < .001) was experienced with the use of aspirin/SPCDs compared with aggressive anticoagulation agents within the risk-stratified cohort. CONCLUSION: The use of aspirin/SPCDs in a risk-stratified TJA population is a safe and cost-effective method of VTE prophylaxis.

Bundled payment initiatives for Medicare and non-Medicare total joint arthroplasty patients at a community hospital: bundles in the real world.

In the setting of current United States healthcare reform, bundled payment initiatives and episode of care payment models for total joint arthroplasty (TJA) have become increasingly common. The following is a review of our results and experience in a community hospital with bundled payment initiatives for both non-Medicare and Medicare TJA patients since 2011. We have successfully decreased the cost of the TJA episode of care in comparison to our historical averages prior to 2011. This cost-reduction has primarily been achieved through decreased length of inpatient stay, increased discharge to home rather than to skilled nursing or inpatient rehabilitation facilities, reduction in implant cost, improvement in readmission rate and migration of cases to lower cost sites of service.

Craving money? Evidence from the laboratory and the field.

Continuing to gamble despite harmful consequences has plagued human life in many ways, from loss-chasing in problem gamblers to reckless investing during stock market bubbles. Here, we propose that these anomalies in human behavior can sometimes reflect Pavlovian perturbations on instrumental behavior. To show this, we combined key elements of Pavlovian psychology literature and standard economic theory into a single model. In it, when a gambling cue such as a gaming machine or a financial asset repeatedly delivers a good outcome, the agent may start engaging with the cue even when the expected value is negative. Next, we transported the theoretical framework into an experimental task and found that participants behaved like the agent in our model. Last, we applied the model to the domain of real-world financial trading and discovered an asset-pricing anomaly suggesting that market participants are susceptible to the purported Pavlovian bias.

Mathematical methods for scaling from within-host to population-scale in infectious disease systems.

Mathematical modellers model infectious disease dynamics at different scales. Within-host models represent the spread of pathogens inside an individual, whilst between-host models track transmission between individuals. However, pathogen dynamics at one scale affect those at another. This has led to the development of multiscale models that connect within-host and between-host dynamics. In this article, we systematically review the literature on multiscale infectious disease modelling according to PRISMA guidelines, dividing previously published models into five categories governing their methodological approaches (Garira (2017)), explaining their benefits and limitations. We provide a primer on developing multiscale models of infectious diseases.

Surgery for rheumatic heart disease in the Northern Territory, Australia, 1997-2016: what have we gained?

BACKGROUND: Between 1964 and 1996, the 10-year survival of patients having valve replacement surgery for rheumatic heart disease (RHD) in the Northern Territory, Australia, was 68%. As medical care has evolved since then, this study aimed to determine whether there has been a corresponding improvement in survival. METHODS: A retrospective study of Aboriginal patients with RHD in the Northern Territory, Australia, having their first valve surgery between 1997 and 2016. Survival was examined using Kaplan-Meier and Cox regression analysis. FINDINGS: The cohort included 281 adults and 61 children. The median (IQR) age at first surgery was 31 (18-42) years; 173/342 (51%) had a valve replacement, 113/342 (33%) had a valve repair and 56/342 (16%) had a commissurotomy. There were 93/342 (27%) deaths during a median (IQR) follow-up of 8 (4-12) years. The overall 10-year survival was 70% (95% CI: 64% to 76%). It was 62% (95% CI: 53% to 70%) in those having valve replacement. There were 204/281 (73%) adults with at least 1 preoperative comorbidity. Preoperative comorbidity was associated with earlier death, the risk of death increasing with each comorbidity (HR: 1.3 (95% CI: 1.2 to 1.5), p<0.001). Preoperative chronic kidney disease (HR 6.5 (95% CI: 3.0 to 14.0) p≤0.001)), coronary artery disease (HR 3.3 (95% CI: 1.3 to 8.4) p=0.012) and pulmonary artery systolic pressure>50 mm Hg before surgery (HR 1.9 (95% CI: 1.2 to 3.1) p=0.007) were independently associated with death. INTERPRETATION: Survival after valve replacement for RHD in this region of Australia has not improved. Although the patients were young, many had multiple comorbidities, which influenced long-term outcomes. The increasing prevalence of complex comorbidity in the region is a barrier to achieving optimal health outcomes.

Comparative genetic analysis of inflammatory bowel disease and type 1 diabetes implicates multiple loci with opposite effects.

Inflammatory bowel disease, including Crohn's disease (CD) and ulcerative colitis (UC), and type 1 diabetes (T1D) are autoimmune diseases that may share common susceptibility pathways. We examined known susceptibility loci for these diseases in a cohort of 1689 CD cases, 777 UC cases, 989 T1D cases and 6197 shared control subjects of European ancestry, who were genotyped by the Illumina HumanHap550 SNP arrays. We identified multiple previously unreported or unconfirmed disease associations, including known CD loci (ICOSLG and TNFSF15) and T1D loci (TNFAIP3) that confer UC risk, known UC loci (HERC2 and IL26) that confer T1D risk and known UC loci (IL10 and CCNY) that confer CD risk. Additionally, we show that T1D risk alleles residing at the PTPN22, IL27, IL18RAP and IL10 loci protect against CD. Furthermore, the strongest risk alleles for T1D within the major histocompatibility complex (MHC) confer strong protection against CD and UC; however, given the multi-allelic nature of the MHC haplotypes, sequencing of the MHC locus will be required to interpret this observation. These results extend our current knowledge on genetic variants that predispose to autoimmunity, and suggest that many loci involved in autoimmunity may be under a balancing selection due to antagonistic pleiotropic effect. Our analysis implies that variants with opposite effects on different diseases may facilitate the maintenance of common susceptibility alleles in human populations, making autoimmune diseases especially amenable to genetic dissection by genome-wide association studies.

Clinical and Patient-Reported Outcomes for Acute Acromioclavicular Joint Fixation are Similar With or Without Allograft Augmentation.

Purpose: To compare functional outcomes, complications, and revision rates between allograft reconstruction and graftless fixation techniques for the treatment of Rockwood grades III-V acute acromioclavicular (AC) joint separation. Methods: Patients who underwent graftless or allograft surgery acutely (≤6 weeks from injury) for Rockwood type III-V AC joint separations from 2012 to 2018 were retrospectively reviewed. Clinic notes and operative reports were identified to confirm the surgical technique and presence of complications including revision, infection, and fracture. In addition, postoperative radiographs were assessed to determine any instances of loss of adequate reduction, and several patient-reported outcomes were collected. Results: In total, 115 patients (52 allograft, 63 graftless) were included in this study with a mean follow-up of 3.8 ± 2.5 years. There were no differences between allograft and graftless patients regarding rates of loss of reduction >5 mm (11.1% graftless vs 21.2% allograft), revision (3.2% vs 1.9%), infection (1.6% vs 3.9%), fracture (3.2% vs 7.7%), or total complication (7.9% vs 9.6%) rates (all P > .05). Patient-reported outcome measures also did not significantly differ between groups. Multivariate analysis found that increased time from injury to repair and increased Rockwood injury grade (grades IV and V) were associated with increased CC distance at postoperative follow-up (P = .008, .050, and .047, respectively). Conclusion: Multivariate analysis found that patients who underwent acute AC joint fixation without allograft augmentation had similar functional outcomes, complications, and revision rates compared with patients who underwent AC joint reconstruction with allograft. Level of Evidence: Level III, retrospective comparative study.

Impact of ambient sound on risk perception in humans: neuroeconomic investigations.

Research in the field of multisensory perception shows that what we hear can influence what we see in a wide range of perceptual tasks. It is however unknown whether this extends to the visual perception of risk, despite the importance of the question in many applied domains where properly assessing risk is crucial, starting with financial trading. To fill this knowledge gap, we ran interviews with professional traders and conducted three laboratory studies using judgments of financial asset risk as a testbed. We provide evidence that the presence of ambient sound impacts risk perception, possibly due to the combination of facilitatory and synesthetic effects of general relevance to the perception of risk in many species as well as humans. We discuss the implications of our findings for various applied domains (e.g., financial, medical, and military decision-making), and raise new questions for future research.

Epidemiology and trends of adult ice hockey injuries presenting to United States emergency departments: A ten-year analysis from 2007-2016.

PURPOSE: The adult population is under-represented in existing ice hockey injury studies, despite the number of United States (US) adult ice hockey players increasing from 103,533 in 2007 to 180,400 in 2016 (74%). This study establishes trends in demographics, injury location, and injury type for adult ice hockey players (≥19 years old) in the United States. METHODS: The National Electronic Injury Surveillance System (NEISS) was queried for all ice hockey injuries from January 1, 2007 to December 31, 2016. Cases under age 19 were excluded. Each injury's narrative text field was reviewed to determine mechanism of injury. RESULTS: A total of 1,653 patients, representing an estimated 68,786 ice-hockey related injuries, presented to NEISS-participating US EDs. The most commonly injured body parts were the face (n = 12,432, 18.1%), head (n = 10,201, 14.8%), shoulder (n = 9,654, 14.0%) and ankle (n = 5,389, 7.8%). The most common diagnoses made were laceration (n = 18,153, 26.4%), strain/sprain (n = 12,202, 17.7%), fracture (n = 10,079, 14.7%), contusion (n = 9,283, 13.5%) and concussion (n = 4,794, 7.0%). The most common mechanisms of injury were falling (n = 11,786, 18.7%), puck contact (n = 10,544, 15.3%) and player contact (n = 9,449, 13.7%). Concussions increased from 46 in 2007 to 928 in 2016 (R2 = 0.8, ß = 0.9, p < 0.001). Females (n = 1,852, 32%) had a higher proportion of head injuries than males (n = 8,349, 13.3%) (IPR = 2.4, p < 0.0001). The 50+ year old cohort showed a significant increase in injuries during the study period (n = 146 vs. 982, R2 = 0.75, ß = 0.87, p = 0.001). CONCLUSIONS: Despite changing trends in age and sex-related demographics, the majority of injuries in this population may be preventable with adequate enforcement of protective gear use. Increased education amongst players, coaches, trainers, orthopaedic surgeons and primary care physicians should be encouraged to minimize injuries.

Surfing-related head injuries presenting to United States emergency departments.

This study examined the incidence and trends of surfing-related and mild traumatic brain injuries that presented to United States emergency departments between 2001 and 2016. Subjects with surging-related head injuries were retrieved from the National Electronic Injury Surveillance System. A weighted total of 34,337 surfing-related head injuries were identified. The annual incidence of surfing-related head injuries insignificantly decreased from 2001 to 2016 (R2 = .119; p = .19). Most common injuries included lacerations (50.4%), blunt head injuries (25.7%), and mild traumatic brain injuries (16.1%). Mild traumatic brain injury incidence and annual percentage increased significantly during the study period (R2 = .251; p = .05 and R2 = .346; p = .02, respectively).

Trends and Epidemiologic Factors Contributing to Soccer-Related Fractures That Presented to Emergency Departments in the United States.

BACKGROUND:: Understanding the risks and trends of soccer-related injuries may prove beneficial in creating preventative strategies against season-ending injuries. HYPOTHESIS:: Soccer-related fractures will have decreased over the past 7 years. STUDY DESIGN:: Descriptive epidemiology study. LEVEL OF EVIDENCE:: Level 3. METHODS:: The National Electronic Injury Surveillance System (NEISS) database was queried to identify soccer-related injuries from 2010 through 2016. The sum of the weighted values provided in the NEISS database was used to determine injury frequency and allowed us to estimate the incidence and annual trends of soccer-related fractures. The estimated annual number of hospital admissions resulting from each fracture location was calculated. Statistical analyses were performed, and a linear regression was used to analyze the annual injury trends, reported as the correlation coefficient. RESULTS:: Over the 6-year period, there were an estimated 1,590,365 soccer-related injuries. The estimated annual frequency of soccer-related injuries slightly increased from 225,910 in 2010 to 226,150 in 2016 ( P = 0.477). The most common injuries were sprains/strains (32.4%), followed by fractures (20.4%). Fractures at the wrist were the most common (18%), while upper leg fractures were the most common soccer-related fractures to be admitted to the hospital (51.6%). The annual trends of the most common soccer-related fractures demonstrated increases in shoulder ( r = 0.740; R2 = 0.547; P = 0.057) and wrist ( r = 0.308; R2 = 0.095; P = 0.502) fractures. There were no significant changes in the trends of soccer-related fractures of the lower arm ( r = 0.009; R2 = 7.3 × 10-5; P = 0.986), finger ( r = 0.679; R2 = 0.460; P = 0.094), lower leg ( r = 0.153; R2 = 0.024; P = 0.743), ankle ( r = 0.650; R2 = 0.422; P = 0.114), toe ( r = 0.417; R2 = 0.174; P = 0.353), or foot ( r = 0.485; R2 = 0.235; P = 0.270). CONCLUSION:: Despite the reported growing number of soccer players in the United States, the overall number of soccer-related injuries has remained relatively stable. Overall, 60% of reported fractures occurred in the upper extremity, with the wrist being the most common site, while lower extremity fractures were the most likely to lead to hospital admission. CLINICAL RELEVANCE:: This study offers an overview of the most common types of fractures that affect soccer players and may prove beneficial in creating preventative strategies against season-ending injuries.

Noncontact sports participation in adolescent idiopathic scoliosis: effects on parent-reported and patient-reported outcomes.

Comparing risks against benefits of adolescent idiopathic scoliosis (AIS) patients participating in sports represents a controversial topic in the literature. Previous studies have reported sports participation as a possible risk factor for AIS development, while others describe its functional benefits for AIS athletes. The objective of this study was to determine if sports participation had an impact on pain, function, mental status, and self-perception of deformity in patients and their parents. Patients had full spine radiographs and completed baseline surveys of demographics, socioeconomics, and patient-reported outcomes (PRO): Scoliosis Research Society (SRS)-30, Body Image Disturbance Questionnaire, and Spinal Appearance Questionnaire (SAQ: Children and Parent). Patients were grouped by their participation (sports) or nonparticipation (no-sports) in noncontact sports. Demographics, radiographic parameters, and PRO were compared using parametric/nonparametric tests with means/medians reported. Linear regression models identified significant predictors of PRO. Forty-nine patients were included (sports: n=29, no-sports: n=20). Both groups had comparable age, sex, BMI, bracing status, and history of physical therapy (all P>0.05). Sports and no-sports also had similar coronal deformity (major Cobb: 31.1° vs. 31.5°). Sagittal alignment profiles (pelvic incidence, pelvic incidence minus lumbar lordosis, thoracic kyphosis, and sagittal vertical axis) were similar between groups (all P>0.05). Sports had better SRS-30 (Function, Self-image, and Total) scores, SAQ-Child Expectations, and SAQ-Parent Total Scores (P<0.05). Regression models revealed major Cobb angle (ß coefficient: -0.312) and sports participation (ß coefficient: 0.422) as significant predictors of SRS-30 Function score (R=0.434, P<0.05). Our data show that for AIS patients with statistically similar bracing status and coronal and sagittal deformities, patients who participated in sports were more likely to have improved functionality, self-image, expectations, and parental perception of deformity. Further investigation is warranted to acquire a comprehensive understanding of the relationship between AIS and patient participation in sports. Maintaining moderate levels of physical activity and participating in safe sports may benefit treatment outcomes. Level of Evidence III - Retrospective Comparative Study.

Total shoulder arthroplasty in octogenarians: Is there a higher risk of adverse outcomes?

This study used the National Surgical Quality Improvement Program to evaluate octogenarians who underwent total shoulder arthroplasty (TSA). Specifically, we evaluated: (1) patient demographics; (2) perioperative factors; and (3) 30-day postoperative complications. Compared to controls, the octogenarians had more females, white patients, lower BMIs, fewer smokers, less functionally independent, higher ASA scores, shorter operative times, and longer LOS. Octogenarians had greater odds for developing any (OR = 2.05; 95%CI, 1.70-2.46), any major (OR = 2.28; 95%CI, 1.66-3.13), and any minor (OR = 1.99; 95%CI, 1.63-2.45) complications. Perioperative risk management strategies for elective TSA in the elderly may help mitigate the increased perioperative risks associated with age.

Demographics and rates of surgical arthroscopy and postoperative rehabilitative preferences of arthroscopists from the Arthroscopy Association of North America (AANA).

Survey of 869 arthroscopists regarding joint-specific arthroscopic procedures and postoperative rehabilitative preferences revealed comparable support for use of supervised physical therapy (SPT) and home exercise programs (HEPs) but stronger preference for joint-specific HEP applications (wrist, knee). Among respondents utilizing HEPs, modality of delivery (verbal/handout/web-based) didn't differ by joint, yet only 2.9% utilized web-based HEPs. This is the first known study to identify postoperative rehabilitation preferences. With 1.77 million estimated arthroscopic procedures annually (mean: 325.4 procedures/respondent), this study highlights under-utilization of web-based HEPs. Reliable, web-based HEPs can improve post-arthroscopic outcomes for patients, arthroscopic surgeons, and rehabilitative specialists while being cost efficient.

S-alk(en)yl-L-cysteine sulfoxides and relative pungency measurements of photosynthetic and nonphotosynthetic tissues of Allium porrum.

Three standard assays for pyruvate gave equivalent measurements of relative pungency for two leek cultivars ( 'Tadorna' and 'Ramona'). Background pyruvate levels varied depending on the assay used, ranging from 0.4 (lactate dehydrogenase) to 1.5 (high-performance liquid chromatography, HPLC) micromol g(-1) fresh weight (FW) on average. The relative pungencies of the two leek cultivars were also compared to total concentrations of the S-alk(en)yl-L-cysteine sulfoxides (RCSOs). The average ratio of EPy to total RCSOs was 10.9, indicating that standard pungency assays underestimate the levels of RCSOs in the tissue. A detailed analysis of 'Tadorna' leaves showed that total RCSO concentrations decreased acropetally. Profiles were composed of (-/+)-methyl-, (-/+)-ethyl-, (+)-propyl-, and (+)-1-propenyl-L-cysteine sulfoxide (MCSO, ECSO, PCSO, and 1-PeCSO, respectively). (+)-PCSO was the most prominent in green (2.4 mg g (-1) FW), yellow (5.5 mg g (-1) FW), and white (3.8 mg g (-1) FW) tissues. The prop(en)yl-L-cysteine sulfoxide derivatives were dominant in tissues that had photosynthetic capacity. The (+)-MCSO levels were high in the bulb (3.6 mg g (-1) FW). Interestingly, detectable levels of (-/+)-ECSO were measured in the leaves ( approximately 0.5 mg g (-1) FW). RCSO profiles of the different tissue regions were similar, but more (+)-PCSO and (+)-1-PeCSO were detected in the bulb. In general, mature upper leaf tissues had lower levels of total RCSOs. Overall, mild extraction methods and a low-temperature HPLC protocol (preferably with long retention times) achieved adequate compound separation and resolution of the diastereomers.

The Role of All-Polyethylene Tibial Components in Modern TKA.

In the modern era of total knee arthroplasty (TKA), a majority of orthopedic surgeons utilize metal-backed tibial (MBT) components rather than nonmodular designs, such as all-polyethylene tibial (APT) components. Interestingly, current clinical evidence does not explain this disproportionate practice by surgeons. The shift in surgeon preference from APT to MBT components occurred in the 1980s following unfavorable results from early studies with APT. However, results from current studies that have revisited the APT versus MBT component comparison demonstrate similar implant survivorship and patient outcomes. Despite equivalent survivorship and improved cost-efficiency, APT components have not achieved equivalent utilization rates with MBT. This review of the current literature, as well as the advantages and disadvantages of APT components, will outline a rationale for the role of APT components in today's cost-driven, outcomes-oriented, patient-centered health-care system.

Unanticipated transient sciatic nerve deficits from intra-wound liposomal bupivacaine injection during total hip arthroplasty.

Liposomal bupivacaine (Exparel®) is a novel formulation of local anesthetic used to provide extended postoperative analgesia as part of a multimodal pain control regimen in patients undergoing total joint arthroplasty. In the three total hip arthroplasty cases described, all patients exhibited a transient loss of neurologic function in the sciatic nerve distribution of the operated extremity lasting between 24 and 72 h during the immediate postoperative period. Due to the nature and duration of the deficits, it was concluded that they likely occurred as a result of unintended injection of the medication in close proximity to the sciatic nerve. To the best of our knowledge, these events have yet to be reported in the current literature. We recommend orthopaedic surgeons pay special attention during infiltration of the medication at the surgical site to avoid postoperative neurological deficits.

Examination of all type 2 diabetes GWAS loci reveals HHEX-IDE as a locus influencing pediatric BMI.

OBJECTIVE: A number of studies have found that BMI in early life influences the risk of developing type 2 diabetes later in life. Our goal was to investigate if any type 2 diabetes variants uncovered through genome-wide association studies (GWAS) impact BMI in childhood. RESEARCH DESIGN AND METHODS: Using data from an ongoing GWAS of pediatric BMI in our cohort, we investigated the association of pediatric BMI with 20 single nucleotide polymorphisms at 18 type 2 diabetes loci uncovered through GWAS, consisting of ADAMTS9, CDC123-CAMK1D, CDKAL1, CDKN2A/B, EXT2, FTO, HHEX-IDE, IGF2BP2, the intragenic region on 11p12, JAZF1, KCNQ1, LOC387761, MTNR1B, NOTCH2, SLC30A8, TCF7L2, THADA, and TSPAN8-LGR5. We randomly partitioned our cohort exactly in half in order to have a discovery cohort (n = 3,592) and a replication cohort (n = 3,592). RESULTS: Our data show that the major type 2 diabetes risk-conferring G allele of rs7923837 at the HHEX-IDE locus was associated with higher pediatric BMI in both the discovery (P = 0.0013 and survived correction for 20 tests) and replication (P = 0.023) sets (combined P = 1.01 x 10(-4)). Association was not detected with any other known type 2 diabetes loci uncovered to date through GWAS except for the well-established FTO. CONCLUSIONS: Our data show that the same genetic HHEX-IDE variant, which is associated with type 2 diabetes from previous studies, also influences pediatric BMI.

A randomized clinical trial to assess the efficacy of intramuscular droperidol for the treatment of acute migraine headache.

In a recent case series, we reported that intramuscular droperidol appeared to be an effective therapy for the treatment of acute migraine headache. The objective of the study was to further assess the efficacy of intramuscular droperidol for the treatment of acute migraine headache. The study design was a randomized, clinical trial set in a community-based ED. The population was a convenience sample of ED patients who met International Headache Society acute migraine criteria. Exclusions included pregnancy, use of narcotic or phenothiazine medications within 24 hours. For the protocol, patients were randomized to 1 of 2 treatment groups. Patients and physicians were blinded as to the treatment provided. Patients recorded their initial pain on a 100mm Visual Analog Scale (VAS) Patients were randomized to receive either 2.5 mg droperidol intramuscularly; the other group received 1.5 mg/kg meperidine intramuscularly. After 30 minutes patients recorded their pain on the VAS and recorded their preference for the medication on a Likert Scale. Physicians recorded the incidence of any side effects and the need for rescue medication. Statistical analysis consisted of categorical variables that were analyzed by chi-square, continuous interval data by t-tests and ordinal data by Mann-Whitney U test. The primary outcome parameters were mean VAS score change and the percentage of patients who wanted to go home without rescue medication. The study had an 80% power to detect a 26 mm difference in the mean change in VAS between groups. Of the 29 patients who were enrolled, 15 received droperidol. Both groups were similar with respect to age (30.7 +/- 8.9 years droperdol v 32.7 +/- 9.9 years meperidine; P =.59), female sex (73% v 71%; P =.91), mean headache duration (24.7 +/- 28.3 v 18.3 +/- 25.8 hours; P =.55). The droperidol group had a higher mean initial VAS score (88 v 76 mm; P =.03). The 2 groups were similar with regard to outcome, including: mean change in VAS score (47 v 37 mm; P =.33), average Likert score (1.1 v 1.9; P =.85), and the percentage of patients who did not want rescue medication (67% v 57%; P =.61). The incidence of sedation was 6.7 v 14.3%. Akathisia occurred in 13.3% of pts who received droperidol. We found that intramuscular droperidol was similar in efficacy to meperidine with a low incidence of side effects.