Role of intravascular ultrasound imaging during endovascular interventions of failing hemodialysis access grafts.

BACKGROUND: Arteriovenous (AV) access graft complications represent a serious complication in patients undergoing hemodialysis. Angiography is one method of visualizing them. However, angiography is not always an effective means of detecting lesions that occur in this context. Intravascular ultrasound (IVUS) is an adjunct modality used to identify stenoses responsible for failing access by identifying multiple stenoses, including those that are most severe. The purpose of this study was to define the value of IVUS in patients with failing AV access grafts by comparing digital subtraction angiography (DSA) alone with DSA followed by IVUS. METHODS: This was a single-center randomized study comparing IVUS with DSA in patients with failing hemodialysis access grafts. It consisted of 100 randomized hemodialysis patients presenting with failing AV access who were being considered for endovascular intervention. Interventions in the control group were guided by DSA alone, whereas interventions in the test group were guided by DSA followed by IVUS. Patients were observed for 6 months after intervention. The primary end point was the time in days to AV access graft failure after the index intervention, expressed as median and interquartile range. Secondary analyses included influence of DSA and IVUS on index procedure decision-making and percentage of patients with AV access graft reinterventions or discontinuation through 3 and 6 months. RESULTS: Median time to first AV graft reintervention or discontinuation was 61 days in the test group and 30 days in the control group (P = .16), with analysis limited to patients who experienced reintervention or discontinuation (n = 59). IVUS resulted in a change in treatment plan in 76% (44/58) of patients, with no treatment change after IVUS in 24% (14/58) of patients. At 6 months, approximately 35% of patients in both the control and test groups remained free from reinterventions (P = .88). At 6 months, approximately 75% of patients in the control group and 80% of patients in the test group remained free from AV graft discontinuation or abandonment (P = .45). CONCLUSIONS: This pilot study suggests that addition of IVUS to standard angiography during endovascular interventions of failing hemodialysis access grafts holds potential to extend the time to the first reintervention. The data support the design and execution of an adequately powered randomized trial with longer follow-up to reliably discern the clinical benefit of IVUS as an addition to standard angiography in the setting of failing AV access grafts.

War and Marriage: Assortative Mating and the World War II GI Bill.

World War II and its subsequent GI Bill have been widely credited with playing a transformative role in American society, but there have been few quantitative analyses of these historical events' broad social effects. We exploit between-cohort variation in the probability of military service to investigate how WWII and the GI Bill altered the structure of marriage, and find that it had important spillover effects beyond its direct effect on men's educational attainment. Our results suggest that the additional education received by returning veterans caused them to "sort" into wives with significantly higher levels of education. This suggests an important mechanism by which socioeconomic status may be passed on to the next generation.

Recipient body mass index and age interact to impact survival after heart transplantation.

Although recipient body mass index (BMI) and age are known risk factors for mortality after heart transplantation, how they interact to influence survival is unknown. Our study utilized the UNOS registry from 1997 to 2012 to define the interaction between BMI and age and its impact on survival after heart transplantation. Recipients were stratified by BMI: underweight (<18.5), normal weight (18.5-24.99), overweight (25-29.99), and either moderate (30-34.99), severe (35-39.99), or very severe (≥40) obesity. Recipients were secondarily stratified based on age: 18-40 (younger recipients), 40-65 (reference group), and ≥65 (advanced age recipients). Among younger recipients, being underweight was associated with improved adjusted survival (HR 0.902; p = 0.010) while higher mortality was seen in younger overweight recipients (HR 1.260; p = 0.005). However, no differences in adjusted survival were appreciated in underweight and overweight advanced age recipients. Obesity (BMI ≥ 30) was associated with increased adjusted mortality in normal age recipients (HR 1.152; p = 0.021) and even more so with young (HR 1.576; p < 0.001) and advanced age recipients (HR 1.292; p = 0.001). These results demonstrate that BMI and age interact to impact survival as age modifies BMI-mortality curves, particularly with younger and advanced age recipients.

Cost effectiveness of duloxetine for osteoarthritis: a Quebec societal perspective.

OBJECTIVE: To assess the cost effectiveness of duloxetine compared to other oral postacetaminophen treatments for osteoarthritis (OA) from a Quebec societal perspective. METHODS: A cost-utility analysis was performed enhancing the Markov model from the 2008 OA guidelines of the National Institute for Health and Clinical Excellence (NICE). The NICE model was extended to include opioid and antidepressant comparators, adding titration, discontinuation, and relevant adverse events (AEs). Comparators included duloxetine, celecoxib, diclofenac, naproxen, hydromorphone, and oxycodone extended release (oxycodone). AEs included gastrointestinal and cardiovascular events associated with nonsteroidal antiinflammatory drugs (NSAIDs), as well as fracture, opioid abuse, and constipation, among others. Costs and incremental cost-effectiveness ratios (ICERs) were estimated in 2011 Canadian dollars. The base case modeled a cohort of 55-year-old patients with OA for a 12-month period of treatment, followed by treatment from a basket of post-discontinuation oral therapies until death. Sensitivity analyses (one-way and probabilistic) were conducted. RESULTS: Overall, naproxen was the least expensive treatment, whereas oxycodone was the most expensive. Duloxetine accumulated the highest number of quality-adjusted life years (QALYs), with an ICER of $36,291 per QALY versus celecoxib. Duloxetine was dominant over opioids. In subgroup analyses, ICERs for duloxetine versus celecoxib were $15,619 and $20,463 for patients at high risk of NSAID-related AEs and patients ages >65 years, respectively. CONCLUSION: Duloxetine was cost effective for a cohort of 55-year-old patients with OA, and more so in older patients and those with greater AE risks.