OBJECTIVE Although intervention in asymptomatic carotid artery stenosis remains controversial, most carotid interventions are performed in asymptomatic individuals. Carotid duplex ultrasound is the diagnostic test that precedes more than 90% of carotid interventions. In terms of economic incentives, providers who perform carotid artery revascularization may experience synergy if they also provide carotid duplex ultrasound, because the diagnostic service is reimbursed and also can lead to referrals for revascularization procedures. To test the hypothesis that providers of revascularization services are incentivized to increase utilization of carotid duplex ultrasound, we compared the utilization of carotid duplex ultrasound among Medicare beneficiaries by three specialties that perform revascularization for carotid stenosis (interventional radiology, vascular surgery, and cardiology) with one that usually does not (diagnostic radiology). MATERIALS AND METHODS We analyzed 100% of procedure-specific claims submitted to Medicare by the four specialties during 2000, 2002, 2004, 2005, 2006, and 2007. Only professional and global components of services approved by Medicare were included. Compounded annual growth rates were used to compare utilization by different specialties. RESULTS Utilization by diagnostic radiology increased at a compound annual growth rate of 1% during 2000-2007. Interventional radiology and vascular surgery experienced higher compound annual growth rates of 3% and 6%, respectively. Utilization by cardiology increased at a rate 11 times that of diagnostic radiology, translating into an additional 960 procedures per 100,000 Medicare beneficiaries by cardiology in 2007 than in 2000. CONCLUSION Medicare beneficiaries are increasingly being tested for carotid artery stenosis, especially by specialties that perform revascularization for carotid stenosis. The health benefits of this practice are uncertain.

The changing healthcare environment offers an opportunity for interventional radiology (IR) to showcase its value-specifically, to demonstrate that IR often offers the better, safer, faster, and less expensive treatment option for various clinical scenarios. The best way to demonstrate the value of IR now and to maintain this value in the future is through implementation of patient-centered care built on standardized care delivery, continuous quality improvement, and effective team dynamics.

PURPOSE: Lower-extremity endovascular interventions are increasingly being performed by vascular surgeons (VSs) and interventional cardiologists (ICs) in addition to interventional radiologists (IRs). Regardless of specialty, well trained, experienced, and dedicated operators are expected to offer the best outcomes. To examine specialty-specific trends, outcomes of percutaneous lower-extremity revascularizations in Medicare beneficiaries were compared according to physician specialty types providing the service. MATERIALS AND METHODS: Medicare Standard Analytical Files that contain longitudinal data of all services (physician, inpatient, outpatient) provided to a 5% sample of Medicare beneficiaries were studied. All claims for percutaneous angioplasty, atherectomy, and stent implantation of lower-extremity arteries during the years 2005-2007 were extracted, and the following outcomes were assessed: mortality, transfusion, intensive care unit (ICU) use, length of stay, and subsequent revascularization or amputation. Outcomes were compared by using regression models adjusted for age, sex, race, emergency department admission, and comorbid conditions. RESULTS: Most outcomes were significantly worse if the service was provided by VSs compared with other vascular specialists. The in-hospital mortality rate for procedures performed by VSs was 19% higher than for those performed by others, but this difference was not significant (P =.351). Adjusted average 1-year procedure costs were significantly lower for IRs ($17,640) than for VSs ($19,012) or ICs ($19,096). CONCLUSIONS: Medicare data show that endovascular lower-extremity revascularization by vascular surgeons results in more transfusion and ICU use, longer hospital stay, more repeat revascularization procedures or amputations, and higher costs compared with procedures performed by interventional radiologists.

PURPOSE To report the results of a standard gamble-type survey conducted to explore patients' heuristics in regard to therapy for peripheral arterial disease (PAD). MATERIALS AND METHODS Patients presenting to a vascular and interventional radiology practice because of suspected PAD were asked to indicate their threshold for risk of amputation during a curative procedure for intermittent claudication (IC) and for risk of death from a curative medication for critical limb ischemia (CLI). Possible relationships of risk threshold with age, gender, ankle-brachial index (ABI), and functional claudication distance were assessed with univariate statistics followed by multivariable generalized linear mixed models of risk acceptance at various risk levels. RESULTS Study participants were 20 patients (40% women), with median age of 64 years, functional claudication distance of 1 block, and ABI of 0.72. In the IC scenario, up to 1% risk of above-knee amputation was found to be the median risk acceptable to patients for undergoing a curative procedure. In the CLI scenario, the median risk acceptance for mortality from a curative medication was up to 1%. The multivariable model for the IC scenario revealed significantly greater acceptance of risk at a given level among older patients and women. No significant predictor was delineated by the multivariable model for the CLI scenario. CONCLUSIONS Overall, patients have a low threshold for complications of PAD therapy, consistent with endovascular but not with open surgical strategies. However, considerable variation in preferences underlines the value of individualized treatment strategies.

BACKGROUND: Low ankle-brachial index (ABI) is associated with increased risk of subsequent cardiovascular disease events, independent of Framingham risk factors, but its ability to improve risk prediction prospectively has not been examined. METHODS: We conducted post-hoc analysis of data from Atherosclerosis Risk in Communities Study (ARIC Study), a large prospective cohort study. 11,594 white and African American (24.2%) men and women, aged 45-64 years, with available Framingham Risk Score (FRS) variables and ABIs at baseline, and without known history of cardiovascular disease or diabetes mellitus or known peripheral arterial disease at baseline were assessed for hard cardiovascular events (hCVD; defined as heart attack, coronary death or stroke) over median follow-up of 10 years. Hazard ratios, C statistic, and net reclassification indexes were calculated to determine the independent predictive ability of ABI compared with FRS. RESULTS: 659 hCVD events occurred. Standardized ABI was significantly associated with hCVD events but with a relatively small effect on events (hazard ratios of 0.85 per standard deviation (95% CI 0.79-0.91)(p-value<0.0001)). The C statistic of FRS modified with ABI was only modestly improved (0.756-0.758). Net reclassification improvement, an indicator of prospective prediction performance, using an ABI threshold of 0.9 was small and statistically insignificant (0.8%, p=0.50). CONCLUSIONS: Although the ABI adjusted for Framingham risk variables was independently associated with subsequent events in terms of hazard ratios, the independent effect of ABI when adjusted for FRS was small in magnitude, and the FRS performed similarly with or without integration or supplementation with ABI. These findings do not provide strong evidence to support FRS modification to include ABI.

BACKGROUND Claudication is a common and disabling symptom of peripheral artery disease that can be treated with medication, supervised exercise (SE), or stent revascularization (ST). METHODS AND RESULTS We randomly assigned 111 patients with aortoiliac peripheral artery disease to receive 1 of 3 treatments: optimal medical care (OMC), OMC plus SE, or OMC plus ST. The primary end point was the change in peak walking time on a graded treadmill test at 6 months compared with baseline. Secondary end points included free-living step activity, quality of life with the Walking Impairment Questionnaire, Peripheral Artery Questionnaire, Medical Outcomes Study 12-Item Short Form, and cardiovascular risk factors. At the 6-month follow-up, change in peak walking time (the primary end point) was greatest for SE, intermediate for ST, and least with OMC (mean change versus baseline, 5.8±4.6, 3.7±4.9, and 1.2±2.6 minutes, respectively; P<0.001 for the comparison of SE versus OMC, P=0.02 for ST versus OMC, and P=0.04 for SE versus ST). Although disease-specific quality of life as assessed by the Walking Impairment Questionnaire and Peripheral Artery Questionnaire also improved with both SE and ST compared with OMC, for most scales, the extent of improvement was greater with ST than SE. Free-living step activity increased more with ST than with either SE or OMC alone (114±274 versus 73±139 versus -6±109 steps per hour), but these differences were not statistically significant. CONCLUSIONS SE results in superior treadmill walking performance than ST, even for those with aortoiliac peripheral artery disease. The contrast between better walking performance for SE and better patient-reported quality of life for ST warrants further study. CLINICAL TRIAL REGISTRATION URL: http://clinicaltrials.gov/ct/show/NCT00132743?order=1. Unique identifier: NCT00132743.

BACKGROUND: Several reports have confirmed the ability of intraoperative periarticular injections to control pain after THA. However, these studies used differing combinations of analgesic agents and the contribution of each, including the local anesthetic agent, is uncertain. Understanding the independent effects of the various agents could assist in improved pain management after surgery. QUESTIONS/PURPOSES: We therefore determined the ability of intraoperative periarticular infiltration of levobupivacaine to (1) reduce postoperative pain,(2) reduce postoperative morphine requirements, and (3) reduce the incidence of nausea and urinary retention. PATIENTS AND METHODS: A double-blinded, randomized, placebo-controlled trial of patients undergoing primary THAs was performed. Patients were randomized to receive a periarticular infiltration of 150 mg levobupivacaine in 60 mL 0.9% saline (n = 45) or a placebo consisting of 60 mL 0.9% saline (n = 46). We obtained a short-form McGill pain score, visual analog scale (VAS), and morphine requirements via patient-controlled analgesia (PCA) as primary measures. Postoperative antiemetic requirements and need for catheterization for urinary retention were determined as secondary measures. RESULTS: Subjectively reported pain scores and the overall intensity scores were similar for both groups in the postoperative period. At the same time the mean morphine consumption was less in the levobupivacaine group, most notable in the first 12 hours after surgery: treatment group 11.5 mg vs control group 21.2 mg. We observed no differences in the frequency of postoperative nausea and vomiting or urinary retention. CONCLUSIONS: Our observations suggest periarticular injection of levobupivacaine can supplement available postoperative analgesic techniques and reduce postoperative morphine requirements after THA. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Marijuana is the most widely used drug of abuse all over the world. The major active constituent of the drug is Δ(9)- tetrahydrocannabinol (Δ(9)-THC). Δ(9)-THC exerts its psychological activities by interacting with the cannabinoid receptors (CB(1) and CB(2)) in the brain. JWH-018, HU-210, and CP-47497, with CB(1) agonist activity (similar to Δ(9)-THC), have been used by the drug culture to spike smokable herbal products to attain psychological effects similar to those obtained by smoking marijuana. The products spiked with these CB(1) agonists are commonly referred to as "Spice" or "K2". The most common compound used in these products is JWH-018 and related compounds (JWH-073 and JWH-250). Little work has been done on the detection of these synthetic cannabimimetic compounds in biological specimens. This report investigated the metabolism of JWH-018 by human liver microsomes, identification of the metabolites of JWH-018 in urine specimen of an individual who admitted use of the drug, and reports on the quantitation of three of its urinary metabolites, namely the 6-OH-, the N-alkyl OH (terminal hydroxyl)-, and the N-alkyl terminal carboxy metabolites using liquid chromatography-tandem mass spectrometry. The concentrations of these metabolites are determined in several forensic urine specimens.

Objective: The forest industry is a major economic sector of Canada. While mechanized machines have reduced injuries workers suffered during manual operations, these machines have also created other musculoskeletal concerns. The purpose of this study was to obtain data regarding upper limb musculoskeletal stress during typical harvesting operations using surface electromyography (EMG). Participants: Students currently training in a forest machine operations course were recruited for this study. Four operators (1 female and 3 males, mean age =24.6 ± 13.4 years, mean height = 172.7 ± 4.6 cm, mean weight=75.4 ± 27.4 kg) participated in this study. Methods: Surface electrodes were placed over the muscles of the upper arm and shoulder to monitor muscular activity during Harvester Simulator operation. Operators were provided specific instructions and visual feedback. Data were collected over a two hours of operation. Results: Preliminary data suggests that while the movements used in the Simulator do not require large force, they are repetitive and constant and can result in muscle fatigue.Conclusions: The EMG data indicated signs of fatigue in several muscles of the upper arms. This preliminary data suggests that while operation of these machines does not require large force contractions, the continuous and repetitive nature of the work can result in muscular fatigue. This suggests that long term operation of mobile machines may result in fatigue and future studies should examine job design.