Effect of direct neuroradiologist participation in physician marketing on imaging volumes in outpatient radiology.

BACKGROUND AND PURPOSE: Over the past several years, decreased demand for and increased supply of imaging services has increased competition among outpatient imaging centers in the United States. This study hypothesizes that using a radiology sales representative and neuroradiologist as a team in marketing and sales will increase imaging referrals in outpatient imaging. MATERIALS AND METHODS: From January to December 2009, baseline monthly physician referral data of CT and MR scans of 19 referring clinicians (neurologists, neurosurgeons, and anesthesiologists) to an outpatient radiology group were collected. During that time, a nonphysician radiology sales representative visited the referring clinicians' offices every 2 weeks. From January to June 2010, the same radiology sales representative visited the referring clinicians' offices every 2 weeks but was accompanied by a neuroradiologist once a month. From July 2010 to June 2011, the same radiology sales representative visited the referring clinicians' offices twice a month without a neuroradiologist. RESULTS: Cross-sectional imaging referral volumes were approximately 2.5 times greater during the 6-month period using the neuroradiologist for direct physician-to-physician marketing when compared with the volumes achieved with the sales representative alone, and continued neuroradiologist involvement in marketing and sales is required to maintain referral volumes over time. CONCLUSIONS: The impact on imaging referral volumes during the 6-month use of the neuroradiologist for direct physician-to-physician marketing in this study supports the assertion that neuroradiologist visits are an important element in establishing and maintaining a relationship with the referring clinician's office and thereby maximizing imaging referrals.

Implementation of a pharmacist-led, multidisciplinary diabetes management team.

PURPOSE: The development, implementation, and evaluation of a pharmacist-led, multidisciplinary diabetes management team (DMT) at a 564-bed medical center in Jackson, Mississippi, are described. SUMMARY: The overwhelming prevalence of diabetes in Mississippi has a major impact on the state's health care system. Mississippi Baptist Health Systems (MBHS) developed a consultation-driven DMT in November 2008. The DMT embraced the multidisciplinary approach by uniting pharmacists, physicians, and other health care providers to optimize the care of patients with diabetes. The DMT initially focused on patients undergoing coronary artery bypass graft (CABG) surgery but also manages patients with a variety of causes of hyperglycemia. To evaluate the success of the DMT, postoperative serum blood glucose levels were collected from January 2008 through December 2010 for patients undergoing CABG at MBHS before and after the implementation of the DMT. The primary outcome was the number of patients with serum blood glucose concentrations exceeding 200 mg/dL. Secondary outcomes measured included the rates of sternal surgical-site infection and the frequency of hypoglycemia. CONCLUSION: Implementation of a pharmacist-led, multidisciplinary DMT helped to achieve intensive glycemic control in CABG patients and decrease the rate of infection.

The use of paclitaxel in the management of early stage breast cancer.

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of paclitaxel in the management of early stage breast cancer based upon the manufacturer's submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The scope was not clearly defined in the manufacturer's submission. Two of the three clinical trials included in the submission report showed that the addition of four cycles of paclitaxel to four cycles of doxorubicin and cyclophosphamide (AC-P) resulted in modest improvements in the two end points of disease-free survival (DFS) and overall survival (OS). The third unpublished study evaluating four cycles of AC followed by paclitaxel or docetaxel in breast cancer did not show any statistically significant differences in DFS or OS between any group. The economic evaluation of paclitaxel for adjuvant therapy in early breast cancer was based on two of the three trials submitted as clinical evidence and used a probabilistic Markov state-transition model. The measure of health benefit was quality-adjusted life-years (QALYs) and the model included direct costs using a UK NHS perspective. The primary analysis compared AC-P with four cycles of AC. The reported incremental cost-effectiveness ratio (ICER) for this comparison was 4726 pounds per additional QALY for AC-P compared with four cycles of AC. The submission did not include a systematic review for clinical or cost-effectiveness evidence. As a result, potentially relevant trials and previously published studies were omitted. The main comparator used did not represent standard care in the UK NHS and a large number of relevant comparators were omitted, including docetaxel. The manufacturer did not consider potentially important patient subgroups defined by baseline risk, and the cost-effectiveness result in the average overall patient population may conceal important variation between subgroups. Overall, although the economic model may have indicated that the addition of four cycles of paclitaxel to four cycles of AC may be cost-effective compared with providing four cycles of AC only, this comparison is not informative to current clinical practice in the UK NHS. In the context of this review it is not possible for the ERG to predict the cost-effectiveness of paclitaxel compared with more appropriate, and potentially more effective, relevant comparators. The guidance issued by NICE in July 2006 as a result of the STA states that paclitaxel is not recommended as an option for the adjuvant treatment of women with early node-positive breast cancer.

Fludarabine phosphate for the first-line treatment of chronic lymphocytic leukaemia.

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of fludarabine phosphate or fludarabine plus cyclophosphamide for the first-line treatment of chronic lymphocytic leukaemia,based upon the evidence submission from Schering Health Care (SHC) to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process.The submission was of good quality with no major errors or omissions in the clinical evidence.Two published studies and seven abstracts were included in the company submission, which showed improvements in overall response and progression-free survival (PFS) and a higher complete response rate in the fludarabine containing arms; however, until the complete data are made available for evaluation these results must be interpreted with caution. The manufacturer's decision-analytic Markov model to estimate the cost-effectiveness of treatment with fludarabine monotherapy, fludarabine plus cyclophosphamide and chlorambucil was considered to be the most relevant source for informing this STA;it was appropriate for the decision problem and the data sources used to inform the model were appropriate from a UK NHS perspective.The incremental cost-effectiveness ratio of fludarabine plus cyclophosphamide compared with chlorambucil from the revised model presented in the manufacturer's addendum was pounds 3244 per additional quality-adjusted life-year.The results were robust to a range of subgroup and sensitivity analyses. Additional sensitivity and survival analyses were carried by the ERG to investigate possible bias in the results. This brought into question the validity of the assumptions underpinning the extrapolation of data over a lifetime time horizon and showed that the ICER estimates submitted by the manufacturer were notcalculated correctly and uncertainty surrounding the decision problems was not expressed fully.Based on these analyses the ERG suggests that further evidence is needed to enable an accurate assessment to be made of the clinical and cost effectiveness of fludarabine as first-line treatment for chronic lymphocytic leukaemia. The guidance issued by NICE in December 2006 as a result of the STA states that fludarabine monotherapy,within its licensed indication, is not recommended for the first-line treatment of chronic lymphocytic leukaemia; no recommendations have been made with respect to fludarabine plus cyclophosphamide combination therapy because the current marketing authorisation does not specifically provide a recommendation that fludarabine should be used concurrently with other drugs for the treatment of chronic lymphocytic leukaemia.

Cetuximab plus radiotherapy for the treatment of locally advanced squamous cell carcinoma of the head and neck.

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of cetuximab plus radiotherapy for the treatment of locally advanced squamous cell carcinoma of the head and neck (LA SCCHN) considered inappropriate for chemoradiotherapy but appropriate for radiotherapy, based upon the evidence submission from Merck Pharmaceuticals to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The manufacturer's submission was generally of good quality and was an accurate representation of the original reference data. One good-quality randomised controlled trial comparing radiotherapy plus cetuximab with radiotherapy alone in patients with stage III or IV non-metastatic LA SCCHN was included, demonstrating that the duration of locoregional control was significantly longer with radiotherapy plus cetuximab than with radiotherapy alone; also, overall and progression-free survival were significantly longer and the overall response rate was significantly better with the combination therapy. Cetuximab did not exacerbate the common toxic effects associated with radiotherapy of the head and neck. No supporting evidence for these findings are available. The patient population in the trial included a high proportion of patients who would be expected to be suitable for chemoradiotherapy and therefore does not match the population described in the submission's decision problem. Also, the radiotherapy regimens used in the trial are not typical of current UK practice. The ERG considered the manufacturer's economic evaluation to comprise the only relevant evidence to consider for the purposes of this STA. The economic model was considered appropriate for the decision problem. The results suggested that cetuximab plus radiotherapy was cost-effective compared with radiotherapy alone under a broad range of different assumptions on the basis of a cost-effectiveness threshold of 20,000 pounds. In the base case the incremental cost-effectiveness ratio of cetuximab plus radiotherapy compared with radiotherapy alone in the treatment of patients with LA SCCHN was 6390 pounds per additional QALY. Simple sensitivity analyses to examine the robustness of the results were undertaken, suggesting that areas of uncertainty that emerged in the modelling are unlikely to have a material effect on the conclusions. The guidance issued by NICE in May 2007 as a result of the STA states that cetuximab in combination with radiotherapy is not recommended for patients with LA SCCHN.

Rupture of the ascending aorta caused by blunt trauma.

BACKGROUND: Rupture of the ascending aorta caused by blunt trauma rarely has been diagnosed and treated. As a result, the clinical manifestations and management of this injury have not been clearly defined. METHODS: We describe the clinical presentation, diagnosis, and management of 3 consecutive patients with ascending aortic rupture treated during the last 3 years. We also review the cases with this injury reported in the English-language literature until 1996. RESULTS: The predominant clinical manifestations of all patients, including reviewed case reports, were those of other organ injuries, and 5 had signs of aortic regurgitation and 1 of cardiac tamponade. The mediastinal silhouette was normal in 6 and widened in 14 patients, 1 of whom had also rupture of the subclavian artery. The aortic tears were managed with primary repair or with graft interposition and the valve injury with replacement or repair. Three of 20 patients died, for an overall mortality of 15%. CONCLUSIONS: Ascending aortic rupture should be considered in any patient with severe blunt trauma who has widened mediastinum or cardiac tamponade, as well as in patients with associated major thoracic injuries. Absence of a widened mediastinal silhouette does not exclude the diagnosis. The repair is relatively straightforward, but survival depends primarily on the severity of associated injuries.

Refinement of the alpha aminooleic acid bioprosthetic valve anticalcification technique.

BACKGROUND: Aminooleic acid treatment has been demonstrated to prevent porcine valve calcification and to protect valvular hemodynamic function. Initial enthusiasm was tempered by histologic studies of these AOA valves, which showed cuspal hematomas, structural loosening, and surface roughening. This prompted a systematic review of the AOA treatment process. Unsolubilized particles of alpha aminooleic acid present in the treatment solution were identified as the cause of mechanical abrasion of valve cusps during processing. These particles were eliminated with a revamped protocol, which included filtration of the AOA solution before valve preparation. METHODS: Porcine aortic valve cusps treated with this modified AOA protocol (AOA II) were studied in a rat subdermal implant model of mineralization. A juvenile sheep trial was then used to confirm the antimineralization effects of AOA II on glutaraldehyde-fixed porcine aortic roots in a circulatory model of accelerated calcification. RESULTS: Retrieved AOA II-treated cusps from the subdermal model were markedly less calcified than control cusps (AOA II, 1 +/- 0, 17 +/- 4, 23 +/- 6, and 17 +/- 10 versus control, 189 +/- 14, 251 +/- 16, 250 +/- 14, and 265 +/- 10 mg calcium/mg sample at 4, 8, 12, and 16 weeks, respectively; p < 0.0001). Morphologic examination of the AOA II cusps of the valves retrieved from the sheep demonstrated freedom from the structural loosening, surface roughening, and hematoma formation that had limited the utility of the original AOA preparation technique. Cusps from AOA II-treated porcine roots had significantly less calcium than control cusps (AOA II, 5.5 +/- 3.0 mg/g; control, 91.2 +/- 19.5 mg/g; p = 0.0004). The aortic walls had similar levels of calcification (AOA II, 156 +/- 73 mg/g; control, 159 +/- 10 mg/g; p = not significant). CONCLUSIONS: These data suggest that the modified AOA technique warrants further evaluation as an antimineralization treatment for glutaraldehyde-fixed porcine bioprostheses.

Unilateral giant bullous emphysema with placental transmogrification of the lung.

A case of severe unilateral bullous emphysema in an otherwise healthy young man is presented to highlight a rare histologic variant termed "placental transmogrification of the lung." The etiology is unknown, but operation has been curative in the small number of cases reported.

Management of the uncontrollable pulmonary air leak with cyanoacrylate glue.

Massive pulmonary air leak from a ruptured bleb in a patient with emphysema may be uncontrollable by the usual methods. A technique is illustrated where fibrin glue, cyanoacrylate glue, and a bovine pericardial patch are used in combination to seal the leak.

Myocardial protection for coronary artery bypass in patients with acute myocardial infarction: resuscitation of ischemic myocardium.

An increasing body of evidence suggests that the majority of myocardial injury that occurs during ischemia and reperfusion is effected during the reperfusion phase. There is also convincing evidence that controlling the conditions of reperfusion and composition of the reperfusate can markedly minimize the ultimate injury following an ischemic insult. Medical reperfusion (PTCA, thrombolytics) has the disadvantage of reperfusing with unmodified whole blood under uncontrolled conditions, whereas surgical reperfusion allows very stringent control of both. A brief review of the pathophysiology of ischemia and reperfusion is presented to gain insight into the mechanisms of injury that can be counteracted by controlling the conditions of reperfusion and composition of the reperfusate. Surgical protocols that have been developed independently at two separate institutions are outlined, along with the experimental data supporting each method, and the advantages and disadvantages of each method. This information should allow implementation of a rational plan of myocardial protection for resuscitation of the ischemic myocardium when performing coronary artery bypass grafting in the setting of acute myocardial ischemia and infarction.

Revascularization for acute regional infarct: superior protection with warm blood cardioplegia.

Continuous retrograde warm blood cardioplegia was compared with two widely used hypothermic myocardial protection techniques in a canine model of acute regional myocardial ischemia with subsequent revascularization. Animals (n = 30) underwent 45 minutes of left anterior descending coronary artery occlusion then cardioplegic arrest (60 minutes), followed by separation from cardiopulmonary bypass and data collection. The cold oxygenated crystalloid cardioplegia group (CC; n = 8) and the cold blood cardioplegia group (CC; n = 10) had cardiopulmonary bypass at 28 degrees C, antegrade arrest, and intermittent retrograde delivery. The warm blood cardioplegia group (WB; n = 12) had normothermic cardiopulmonary bypass, antegrade arrest, and continuous retrograde delivery. Overall ventricular function (preload recruitable stroke work relationship; ergs x 10(3)/mL) was significantly (p < 0.001) better for WB (WB, 80 +/- 11; CB, 67 +/- 13; CC, 57 +/- 12). Systolic function (maximum elastance relationship; mm Hg/mL) was also significantly (p < 0.001) better for WB (WB, 11.6 +/- 3.6; CB, 8.6 +/- 2.7; CC, 6.2 +/- 1.3). Diastolic function (stress-strain relationship; dynes x 10(3)/cm2) revealed significantly (p < 0.001) decreased compliance for CC (WB, 20 +/- 6; CB, 19 +/- 7; CC, 27 +/- 11). Left anterior descending coronary artery regional adenosine triphosphate/adenosine diphosphate ratios were significantly (p = 0.02) worse for CC (WB, 10.2 +/- 2.3; CB, 9.4 +/- 2.6; CC, 5.6 +/- 1.5). Myocardial edema significantly (p = 0.03) increased over time only in the CC animals (WB, 0.4% +/- 2.3%; CB, -0.3% +/- 3.6%; CC, 5.5% +/- 2.3%). In this model of acute regional myocardial ischemia and revascularization, continuous retrograde warm aerobic blood cardioplegia provided superior myocardial protection compared with cold oxygenated crystalloid cardioplegia with intermediate results for cold blood cardioplegia.

Warm blood cardioplegia: superior protection after acute myocardial ischemia.

Three myocardial protection techniques were studied in a canine model of acute myocardial ischemia with subsequent revascularization. Eighteen animals were randomly assigned to one of three treatment regimens: cold oxygenated crystalloid cardioplegia (CC), cold blood cardioplegia with modified reperfusate (CB), and continuous aerobic warm blood cardioplegia (WB) (n = 6 per group). Systemic hypothermic cardiopulmonary bypass (28 degrees C), antegrade arrest, and intermittent retrograde and antegrade delivery were used for the CC and CB groups. Systemic normothermic cardiopulmonary bypass, antegrade arrest, and continuous retrograde delivery were used for the WB group. Fifteen minutes of warm global ischemia was followed by occlusion of the left anterior descending coronary artery (15-minute duration) and simultaneous initiation of cardioplegic arrest (60-minute duration) to simulate clinical revascularization. After reperfusion, the animals were separated from cardiopulmonary bypass. Myocardial function, electrocardiogram, myocardial energetics, water content, histopathology, and defibrillation requirements were compared between groups. There was no significant difference in maximum elastance, myocardial oxygen consumption, myocardial edema, or histopathologic evidence of injury between groups. However, overall ventricular function, assessed by the slope of the preload recruitable stroke work relationship, was significantly better for the WB group (p = 0.04) (WB, 73 +/- 9; CB, 56 +/- 7; CC, 47 +/- 5). Diastolic function as assessed by the slope of the stress-strain relationship was significantly worse overall for the cold groups (p = 0.001) (WB, 20 +/- 2.2; CB, 39 +/- 1.3; CC, 37 +/- 3.1). Myocardial injury as assessed by ST segment elevation (millimeters) was less for the WB group (p = 0.03) (WB, 0.4 +/- 0.3; CB, 1.7 +/- 0.2; CC, 1.6 +/- 0.7). Countershocks necessary to restore sinus rhythm after cross-clamp removal were fewer in the WB group (p = 0.03) (WB, 0.8 +/- 0.3; CB, 4.0 +/- 1.2; CC, 5.5 +/- 1.5). In this model of acute global myocardial ischemia, continuous aerobic warm blood cardioplegia has important advantages over two widely used clinical hypothermic protection techniques.

Value of laser-assisted angioplasty in the community hospital.

The experience with laser-assisted angioplasty at a community hospital was reviewed. One hundred twenty patients required angioplasty during a 7-month period, and in only 17-13 of whom had superficial femoral artery occlusions--was the use of lasers deemed appropriate. The success rate was 65% for laser-assisted angioplasty and 98% for balloon angioplasty. Laser-assisted angioplasty was the initial intervention in eight of the 13 superficial femoral artery occlusions. In two cases, a wire had been first advanced across the lesion, and in three cases, attempts to cross the lesion with a wire had been unsuccessful. The availability of the laser did not significantly increase the number of cases amenable to angioplasty, and at present laser angioplasty, does not seem to be cost-effective for community hospitals.

Digital subtraction angiography in head and neck radiology.

Intravenous digital subtraction angiography (IVDSA) was used to evaluate 44 patients with suspected otolaryngologic abnormalities. Sixteen had IVDSA for pulsatile tinnitus or suspected glomus tumor of the petrous bone. Nine patients were evaluated because of pulsatile neck masses, and 12 others had suspected tumors of the neck, face, and paranasal sinuses. Seven had IVDSA following head and neck trauma. The technique of examination is described. The current indications of IVDSA in head and neck radiology are discussed. It is concluded that IVDSA is a suitable substitute for conventional angiography for many otolaryngologic conditions and, because of its safety, can be used more liberally.

Digital subtraction angiography of glomus tympanicum and jugulare tumors.

Radiologic procedures used to evaluate patients with suspected glomus tumor have included plain skull radiography, temporal bone tomography, computed tomography, and cerebral angiography. Of these, only angiography has proven reliable as a screening procedure for small glomus tympanicum and jugulare tumors. Digital subtraction angiography was used as the initial examination for suspected paraganglioma in 14 patients. Intravenous digital subtraction angiography proved to be an acceptable screening tool for these highly vascular tumors. Also, intraarterial digital subtraction angiography proved very satisfactory for mapping of tumor blood supply, which greatly simplified preoperative embolization. Effectiveness of therapy was readily ascertained by serial follow-up intravenous digital subtraction angiography.

Comparison of iohexol with meglumine-Na diatrizoate for intravenous digital subtraction angiography.

Iohexol, a new non-ionic water-soluble contrast medium, was tested for digital intravenous angiography of the cervical and intracranial vessels. In a double blind study involving 40 adult patients, iohexol and meglumine-Na diatrizoate were compared for safety, patient tolerance, and radiographic image quality. Iohexol was shown to be safe and generally produced less patient discomfort, leading to a lower incidence of motion, swallowing or cough artifacts.