Minority Access Research Articles

IP189. Larger Sheath Size for Infrainguinal Endovascular Intervention Is Associated With Minor Access Site Hematomas and Longer Length of Stay

IP189. Larger Sheath Size for Infrainguinal Endovascular Intervention Is Associated With Minor Access Site Hematomas and Longer Length of Stay

Increasing Underrepresented Minority Access to Healthcare Professions through Pipeline Programming [14N

INTRODUCTION: The Robert Wood Johnson Foundation Center for Health Policy (RWJF-CHP) at Meharry Medical College (MMC) partnered with a local high school to create a pipeline program that trains minority students enrolled in the Community Health Academy (CHA). The program provided clinical training to successfully pass the certified clinical medical assistant (CCMA) exam that allows trained professionals to perform clinical duties and assist providers in the healthcare setting. It is expected that these students will enroll in an undergraduate institution affiliated with MMC and ultimately matriculate into one of MMC's Professional Schools. METHODS: Twenty-five students were selected from 100 applicants by the CHA committee to participate in the one year pilot study. Students submitted resumes, personal statements, and were interviewed. Parental consents were obtained. The RWJF-CHP implemented clinical and educational training which included Science Symposiums, Clinical Internships, Medical Simulation Training, and Tutoring by Meharry faculty, residents, and students. RESULTS: Prior to 2017, 25/25 took the CCMA exam and did not pass it. In 2018, 20/25 passed the exam on their first attempt. The current passage rate for students after implementation of this pilot pipeline program for one year was 80%. CONCLUSION: Through this pipeline opportunity, students learned clinical skills and earned a certification necessary to work in the medical field. This project demonstrated that the pipeline model is effective in increasing minorities in the healthcare field. Further implications are to expand the model to include other high schools in the Nashville area.

Rehabilitation and recovery for ethnic minority patients with severe mental illness

SUMMARYThere is growing evidence to support recovery and rehabilitation services and interventions for people with severe mental illness (SMI). However, those from ethnic minority communities face inequitable outcomes and access to mental health services and poorer functional outcomes. This article reviews the evidence and discusses facilitators and barriers in the recovery journey of people with SMI from ethnic minority groups. Although there is limited evidence for specific interventions for ethnic minority patients, areas for future study and action are discussed.LEARNING OBJECTIVESAfter reading this article you will be able to:•understand the scope of rehabilitation practices and interventions and evidence for use with ethnic minority patients with severe mental illness•describe differences and similarities in the conceptualisation of recovery by majority and minority ethnic communities•appreciate facilitators and barriers to rehabilitation and recovery for ethnic minority patients with SMI.DECLARATION OF INTERESTNone.

Tobacco control: prevention and cessation in Europe

Reasons for high smoking prevalence in Europe compared to Australia and North America are low prices of tobacco adjusted for purchasing power and poor smoke-free legislation and enforcement in Central and Eastern Europe. High rates of passive smoking in Czechia, Slovakia, Poland and Austria are associated with weak implementation of smoke-free public rooms, especially in the hospitality industry. In 2018 Austria cancelled the smoking ban in all bars and restaurants and continued to allow access to minors, while Hungary since 2012 showed remarkable success by limiting supply of cigarettes and by banning access of minors to tobacco shops. Even more advanced are Western European countries because of lower affordability of cigarettes, ban of smoking rooms and tobacco advertising, plain packaging and public information campaigns. Smoking cessation services across Europe make use of quitlines, provide internet counseling and apps for self-help. Cooperation with physicians should be improved and could help oncologists to combine cancer screening with smoking cessation. Cancer therapy is more successful after smoking cessation.

Characterization of the Interaction between ISTL1 and Exo70E2 in Arabidopsis

Internal and external stimuli at the plasma membrane are the cause of dynamic changes that affect the composition of the plasma membrane which is responsible for the proper responses, survival, and development of an organism. The Endosomal Sorting Complex Required for Transport, otherwise known as ESCRT, is a highly conserved pathway in all eukaryotes. This pathway allows for endocytosis, and endosomal trafficking which tags proteins for degradation. It is also responsible for the sorting of endocytic vesicles to the vacuole. This mediates the responses of plants. It has also been noted that there is a possible relationship between the ESCRT pathway and the exocyst. The exocyst is an octameric protein complex that directs vesicles after the Golgi complex to specific destinations of the the plasma membrane. It has recently been proposed that Exo70 proteins localize vesicle traffic.Support or Funding InformationNational Science FoundationNIH Minority Access to Research (MARC) 5 T34 GM 8395‐29 California State University NorthridgeOtegui LabThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Lack of Diversity in Cell Lines Prevents Minorities Access to Precision Medicine

Lack of Diversity in Cell Lines Prevents Minorities Access to Precision Medicine

03:54 PM Abstract No. 157 Single-institution experience of suction thrombectomy with veno-venous bypass (Angiovac Device): various applications and team-based approach

To evaluate the efficiency and safety of suction trombectomy with veno-venous bypass in a tertiary care center. To discuss various clinical applications of the device and the procedure. Retrospective evaluation of patients who have received treatment with the Angiovac device (Angiodyamics, Latham, NY) were analyzed from 2013 through 2018. 40 patients who received treatment were identified (16 male, 14 female, age range: 17-83 years). To our knowledge, this is the highest number of procedures reported by a single institution. Twenty-two patients received treatment for iliocaval DVT (8 patients IVC filter related), 15 patients for atrial clot (8 patients with atrial clot with submassive/massive pulmonary embolism, 2 for right atrial clot with ASD, 5 for valve vegetations) and, 2 patients for embolic protection during mesenteric thrombotic clot removal through transjugular intrahepatic portosystemic shunt. Successful clot removal was achieved in 25/30 patients (all patients with iliocaval DVT). Complete clot removal failed in 3 cases with right atrial clot, two of which were chronic, and both cases of mesenteric venous thrombosis. Three major (mesenteric hematoma, intraprocedural non clinical PE, massive PE resulting in death 22 days after a successful procedure) and two minor (access site hematoma) complications were noted. Two patients died prior to discharge for reasons unrelated to the procedure. 28 patients received imaging follow up which confirmed absence of clot. An “Angiovac Team” with members consisting of a cardiothoracic surgeon, a perfusionist, a cardiac anesthesiologist, an inteventional radiologist, experienced technologists and company representatives were established and each case was performed within 24-48 hours of a decision to perform the procedure in an effective manner. Suction thrombectomy utilizing the Angiovac device achieves rapid removal of acute or subacute high burden clot in an effective and safe manner. The logistical burdens could be overcome with a well-established interventional team consisting of various specialties leading to safe and reproducible results.

Disparities in Rates of Surgical Intervention Among Racial and Ethnic Minorities in Medicare Accountable Care Organizations.

To assess the effect of Accountable Care Organizations (ACOs) on the use of surgical services among racial and ethnic minorities. Health reform efforts were expected to reduce healthcare disparities. The impact of ACOs on existing disparities in access to surgical care remains unknown. We used national Medicare data (2009-2014) to compare rates of surgery among white, African American, Hispanic, and Asian Medicare beneficiaries for coronary artery bypass grafting, colectomy, total hip arthroplasty, hip fracture repair, and lumbar spine surgery. We performed a pre-post difference in differences analysis between African American, Hispanic, and Asian patients receiving surgical care in ACO and non-ACO organizations before and after the implementation of ACOs. The time period 2009 to 2011 was considered the pre-ACO period, and 2012 to 2014 the post-ACO period. Rates of surgical intervention in the ACO cohort were significantly lower (P < 0.001) as compared to non-ACOs for whites, African Americans, Hispanics, and Asians in both the pre- and post-ACO periods. There was no significant difference in the adjusted change in the rate of surgical interventions among minority patients as compared to whites in ACOs and non-ACOs between 2009 to 2011 and 2012 to 2014. The odds of receiving surgical intervention were lowest for minority patients in ACOs during the post-ACO period (P < 0.001). We found persistent differences in the use of surgery among racial and ethnic minorities between the time periods 2009 to 2011 and 2012 to 2014. These disparities were not impacted by the formation of ACOs. Programs that specifically incentivize ACOs to improve surgical access for minorities may be necessary.

03:09 PM Abstract No. 64 Switching from transfemoral to transradial approach for uterine artery embolization: is there a learning curve?

Uterine artery embolization (UAE) has been traditionally performed with transfemoral approach (TFA) with very low complication rate and great technical and clinical success. Transradial approach (TRA) has now been shown to be feasible for uterine artery embolization. However, there is a need to show that TRA is non-inferior in terms of technical and clinical success and complication rates as compared to established practice. In this IRB-approved, HIPAA-compliant retrospective study, consecutive patients that underwent UAE to treat fibroid-related symptoms in a single tertiary academic hospital between 05/2014 – 06/2018 were included. In 11/2016 routine access for UAE was changed from TFA to TRA. Patient’s and procedure characteristics, clinical and technical success and complications rates were compared. There were 91 patients (45±5 yrs) in TFA group and 91 patients (46±5 yrs) in TRA with one case of crossover to TFA due to vasospasm. There was no difference in fluoroscopy time (41±16 vs. 40±14min, p=0.56) or radiation exposure (660±711 vs. 679±998mGy, p=0.88) between TFA and TRA groups. More women were discharged home the same day with TRA (30/91, 33%) than with TFA (4/91, 4%), p=0.002. Only 2 patients (2/30, 7%) represented to ED for pain control among patients who were discharged home the same day in TRA group vs. 1/4, 25% in TFA group. There was a similar low rate of minor access site complication in each group: in TFA group (6/91, 7%): 5 patients with groin hematomas and 2 patients with groin pain vs. in TRA group (4/91, 4%): 3 patients with transient focal occlusion of the radial artery and one patient with focal pain, all resolved with conservative management. Imaging at 3 months showed similar rate of uterine volume reduction: 38±17% in TFA vs. 33±19% in TRA group, p=0.18. No residual enhancement was noted in 43/52, 83% in TFA vs. 65/76, 85% in TRA group in patients with MRI at 3 months, p=0.66. In this retrospective study transradial approach was shown to have similar technical and clinical success rate with similar very low rate of access site complications as compared to transfemoral approach. TRA allowed same day discharge in 33% of patients.

Associationalism and Panopticism in American Democracy: An Analysis of Jewish Power

This paper combines the theories of Alexis de Tocqueville and Michel Foucault to explain the political power Jewish associations have accrued in the United States. By applying Tocqueville’s idea of associationalism and Foucault’s interpretation of panopticism together, it is possible to analyze how the majority and minority access and respond to power in American Democracy. Through associationalism, American Jews could make themselves visible without breaching any norms—and could become part of the structure of panoptic surveillance as well. Jewish experiences as a diaspora people prepared Jewish associations for the challenges of assimilation and political organizing. This research draws upon mostly Tocqueville and Foucault’s classic texts, articles on Jewish studies, and primary sources including memoirs.

A2 to B Kidney Transplantation in the Post-Kidney Allocation System Era: A 3-year Experience with Anti-A Titers, Outcomes, and Cost

The new kidney allocation systems (KAS) instituted December 2014 permitted A2 to B deceased donor kidney transplantation (DDKTx) to improve access and reduce disparities in wait time for minorities. A recent United Network for Organ Sharing (UNOS) analysis, however, indicated only 4.5% of B candidates were registered for A2 kidneys. Cited barriers to A2 to B DDKTx include titer thresholds, patient eligibility, and increased costs. There are little published data on post-transplantation anti-A titers or outcomes of A2 to B DDKTx since this allocation change. We conducted a retrospective, single center, cohort analysis of 29 consecutive A2 to B and 50B to B DDKTx from December 2014 to December 2017. Pre- and postoperative anti-A titers were monitored prospectively. Outcomes included post-transplant anti-A titers, patient and graft survival, renal function, and hospital costs. African Americans comprised 72% of the A2 to B and 60% of the B to B group. There was no difference in mean wait time (58.8 vs 70.8 months). Paired tests indicated that anti-A IgG titers in A2 to B DDKTx were increased at discharge (p= 0.001) and at 4 weeks (p= 0.037). There were no significant differences in patient or graft survival, serum creatinine (SCr), or estimated glomerular filtration rate (eGFR), but the trajectories of SCr and eGFR differed between groups over the follow-up period. A2 to B had significantly higher mean transplant total hospital costs ($114,638 vs $91,697, p < 0.001) and hospital costs net organ acquisition costs ($42,356 vs $20,983, p < 0.001). Initial experience under KAS shows comparable outcomes for A2 to B vs B to B DDKTx. Anti-A titers increased significantly post-transplantation, but did not adversely affect outcomes. Hospital costs were significantly higher with A2 to B DDKTx. Transplant programs, regulators, and payors will need to weigh improved access for minorities with increased costs.

21. Assessment of Adolescent Decision-Making Capacity For Pharmacist Access To Hormonal Contraception

Multiple states allow pharmacists to prescribe combined hormonal contraception. In many cases, pharmacy access is restricted or unavailable for minors due in part to concerns about minor’s decision-making capacity. Our objective was to examine adolescents’ decision-making capacity for contraception after a simulated pharmacist prescribing process. As part of a larger study of minor access to contraception in a pharmacy setting, we recruited 53 females, ages 14-21, from primary care and subspecialty clinics (neurology, rheumatology, cardiology, oversampled for contraindications). Participants underwent a simulated pharmacist prescribing process, which included completion of a self-screener for medical contraindications, providing the participant with a menu of available options based upon their screener, and method specific counseling. The simulation was followed by a validated, semi-structured capacity assessment using the MacArthur Competency Assessment Tool - Treatment (MacCAT-T). The tool assesses four components of decision-making: (1) understanding of the treatment, (2) appreciation for how the decision will affect the young person personally, (3) logical reasoning and balancing risks/benefits, and (4) making a voluntary choice. Questions are open-ended with follow-up probes to elucidate decision-making processes. Interviews are scored out of 20 using a pre-determined scoring rubric, with a higher score indicating a greater level of decision-making capacity. Predictors included demographics, health literacy (rapid assessment of adult literacy in medicine (REALM), socioeconomic status (Family Affluence Scale II), sexual behavior, presence of a chronic illness (Children with Special Health Care Needs questionnaire). Quantitative data were analyzed using correlation, t-tests and ANOVA. Multiple regression was not done as there was not sufficient variation in the outcome. The open-ended questions were analyzed qualitatively using thematic analysis to identify key concepts related to decision-making capacity and opinions regarding contraception and pharmacy access. Of the 53 participants, 58% were from primary care clinics, 42% subspecialties; 70% were under 18 years of age; 38% African American, 36% white, 11% Latina. Participants scored high on the MacCAT-T, with little variation in the scores (18.8 (+/- 1.9)) and no correlation with any hypothesis variables. Examining differences by age below or above 18 showed no differences between sub-scores in understanding (5.5 v. 5.6), appreciation (3.9 vs. 4.0), reasoning (7.7 vs. 7.6) and choice (1.6 vs. 1.6). In bivariate analysis, neither age, ethnicity, clinic type, insurance, family affluence, sexual activity or chronic illness were statistically significant with total MacCAT-T scores. One variable found to be significantly associated was medical literacy (p<0.001). Key themes included stigma around contraception use and sexual activity. Some found discussing heavy or painful menstrual cycles as a strategy for more acceptable contraceptive use—both with parents and their larger community. Participants found pharmacy access to be a convenient and discreet option. However, they did raise concerns about pharmacists’ knowledge and understanding of their chronic illness. Furthermore, some participants preferred their clinical provider due to their already established relationship and knowledge of medical history. Minors demonstrated high levels of decision-making capacity regarding contraception, comparable to young adults. These data support expansion of pharmacy access to hormonal contraception to adolescents of all ages.

The resegregation of public schools? Examining Parents Involved in practice

This study investigated the efficacy of race-neutral student assignment policies following the 2007 Supreme Court decision in Parents Involved. Highlighting one urban school district—Chicago Public Schools—we examined differences in racial composition at their elite, “selective enrollment” high schools before and after voluntary race-based policies became unconstitutional. Using repeated measures ANOVA, we found the transition from racial to socioeconomic criteria have resegregated these schools— significantly reducing African- and Asian-American enrollment. We argue the Supreme Court’s decision to strike down voluntary race-based student assignment policies has contributed to local policy changes for urban districts like Chicago, reducing minority access and opportunity.

Zumba in the Postindustrial Midwest: Minority Women and Access to Physical Fitness

Historically, minority women have had limited access to health care resources. Healthy People 2020 identified the promotion of activity and wellness as a key for eliminating heath disparities in ethnic minorities, as minority women are not significant consumers of exercise programming. This study explored participation of a sample of underserved African American women in an individualized Zumba exercise program. The underserved sample was taken from a postindustrial Midwestern city. Participants (n = 35, M age = 45.75) completed a 4-month aerobic intervention program offered through an accessible gym. At program completion, they responded to a semistructured survey that gauged reasons for participation, perceived enjoyment, and effectiveness. In addition, the survey prompted recommendations and suggestions for future programming. Low cost and entertainment aspects were the most commonly cited reasons for participation. Most participants found the program enjoyable and effective and expressed interest for participating in similar events in the future.Subscribe to TPE

Efficacy and Safety of Subcutaneous Fellow's Stitch Using "Fisherman's Knot" Technique to Achieve Large Caliber (> 10 French) Venous Hemostasis.

BackgroundAmong patients undergoing intervention involving venous access, various techniques have been implemented to achieve hemostasis in order to reduce local access site complications, to decrease length of stay and to facilitate early ambulation. We aimed to assess the efficacy and safety of fellow’s stitch using “fisherman’s knot” (figure of Z (FoZ)) technique when compared with conventional manual compression for immediate closure of large venous sheath (> 10 French (Fr)).MethodsBetween November 2012 and March 2019, 949 patients underwent various interventions which involved venous access requiring hemostasis. All the patients were anticoagulated with heparin during the procedure. In a sequential allocation, fellow’s stitch using “fisherman’s knot” (group I: n = 384) and conventional manual compression (group II: n = 365) were used in achieving hemostasis at right/left femoral venous access site following sheath removal (> 12 Fr). A 0-Vicryl suture was used to make one deep stitch just distal to entry of sheath and one superficial stitch just proximal to entry site, thereby creating an FoZ. A fisherman’s knot was then tied, and knot was pushed down while sheath was removed. In cases where immediate hemostasis was not achieved, it was compressed for 2 min to achieve it.ResultsThe mean age of 949 patients was 13.1 ± 8.2 years where male (n = 574; 65%) outnumbered female (n = 375; 35%). In group I, hemostasis was achieved immediately after tying the knot in 343 (89.3%) patients, while within ≤ 2 min of light pressure in 41 (10.7%) patients. Five (1.3%) patients had failure of stitch as suture snapped during knotting, and hemostasis was achieved by manual compression as per protocol in group I. The median time to hemostasis (1.1 vs. 14.3 min, P < 0.001), ambulation (3.3 vs. 18.9 h, P < 0.01) and hospital stay (24.6 vs. 36.8 h, P < 0.001) was significantly shorter in group I compared to group II. The minor vascular access site complications in form of hematoma (n = 6 (1.6%) vs. n = 1 (0.2%); P < 0.001), and thrombosis at femoral vein (n = 4 (1.1%) vs. n = 0 (0%); P < 0.001) were significantly higher in group II when compared to group I. The differences regarding re-bleeding and formation of arterio-venous fistula between both the groups were statistically insignificant.ConclusionThe fellow’s stitch using “fisherman’s knot” or “FoZ” suture is a simple, efficacious and safe technique to achieve an immediate hemostasis after removal of larger venous sheath (> 10 Fr).

A Hermeneutic Phenomenological Study of Teen Mothers Who Graduated from an Alternative School

Many studies support the recurring theme that due to early childbearing, the education of teen mothers is jeopardized. Negative stereotypes towards them also prevail representing the view that teen mothers are wayward, divergent, and burdensome to society. However, there is support from the literature that the majority of them maintain career and educational aspirations. Moreover, access of pregnant minors and teen mothers to public education is guaranteed by law. With this in view, the researcher explored the educational experiences of teen mothers, particularly those who chose to enroll in and eventually graduated from an alternative public school that exclusively serves this population. A hermeneutic phenomenological approach was used in interviewing seven teen mothers who graduated from an alternative school. This qualitative method was useful in understanding subjective experiences, forming insights about individuals’ motivations and actions. The participants were selected by purposive sampling. Inductive analysis of the data indicated that attending an alternative school provided academic reengagement, structure, motivation, and a safe and caring learning environment for the participants. This study makes a contribution to the scant literature about the educational experiences of teen mothers, providing evidence that they strive to succeed and can succeed educationally when given support and access to academic services. The conclusions serve as a counter discourse to the prevailing negative perceptions towards this challenged population.

Is Immigrant Status Associated With Cervical Cancer Screening Among Women in Canada? Results From a Cross-Sectional Study.

Cervical cancer accounts for the highest mortality rate from cancer in women worldwide. Despite widespread availability of cervical cancer screening programs in Canada, immigrant women are largely underscreened. The most recently published Canadian-wide study evaluated screening uptake from 2001 to 2002. The objectives included identifying the prevalence of underscreened women in Canada, determining the risk of underscreening for cervical cancer among immigrant women, and providing an update on Canadian screening practices. This study included women aged 20 to 69 who completed the Canadian Community Health Survey 2012. The prevalence of underscreening among Canadian-born and immigrant women was estimated. A log-binomial model was fit to estimate the relative risk (RR) of underscreening for immigrant women while controlling for age, income level, visible minority status, smoking status, and access to a regular physician. A secondary analysis compared immigrants residing in Canada for greater or less than 10 years to Canadian-born women. Of the 17854 women eligible for this study, 18.6% of Canadian-born women and 28.9% of immigrant women were underscreened (P<0.05). Immigrant women were at significantly higher risk of being underscreened compared with Canadian-born women (RR 1.32; 95% CI 1.20-1.45). The relative risk did not change when stratifying by length of time since immigration (RRrecent immigrant 1.32; 95% CI 1.16-1.50; and RRlong-term immigrant 1.32; 95% CI 1.19-1.47). Immigrant status continues to be associated with a significantly higher risk of underscreening, irrespective of time in Canada. Social and educational programs targeted towards immigrants are needed to mitigate the disparity in cervical cancer screening.

Support vector machine model for prediction of accidents on non-urban sections of highways

A support vector machine (SVM) model is proposed for accident prediction on non-urban sections of highways as an alternative to conventionally used fixed-effect or random-effect negative binomial (FENB/RENB) regression models. Road accident data over a period of 8 years on different sections of eight highways in India were collected from police records. In addition, data relating to road geometry, traffic and road environment related variables were collected through field studies. A total of 222 data points was gathered by dividing highways into sections with certain uniform geometric characteristics. Two modelling approaches were used (RENB and SVM models) to predict accident frequencies. The results showed encouraging performance of the SVM model in comparison with the RENB model in terms of both the correlation coefficient and root mean square error values. The SVM, originating from statistical learning theory, can better solve over-fitting and local minima problems and the results indicate that this approach can effectively be used as an alternative to the RENB approach if the sole aim is to predict crashes. The results clearly indicate that, to improve safety on Indian highways, minor access roads to highways and service roads need to be properly designed and controlled and the dispersion of speeds needs to be reduced.

Effect of an equal-access military health system on racial disparities in colorectal cancer screening.

Racial disparities in colorectal cancer (CRC) screening are frequently attributed to variations in insurance status. The objective of this study was to ascertain whether universal insurance would lead to more equitable utilization of CRC screening for black patients in comparison with white patients. Claims data from TRICARE (insurance coverage for active, reserve, and retired members of the US Armed Services and their dependents) for 2007-2010 were queried for adults aged 50 years in 2007, and they were followed forward in time for 4 years (ages, 50-53 years) to identify their first lower endoscopy and/or fecal occult blood test (FOBT). Variations in CRC screening were compared with descriptive statistics and multivariate logistic regression. Among the 24,944 patients studied, 69.2% were white, 20.3% were black, 4.9% were Asian, and 5.6% were other. Overall, 54.0% received any screening: 83.7% received endoscopy, and 16.3% received FOBT alone. Compared with whites, black patients had higher screening rates (56.5%) and had 20% higher risk-adjusted odds of being screened (95% confidence interval [CI], 1.11-1.29). Asian patients had a likelihood of screening similar to that of white patients (odds ratio [OR], 1.06; 95% CI, 0.92-1.23). Females (OR, 1.20; 95% CI, 1.10-1.33), active-duty personnel (OR, 1.15; 95% CI, 1.06-1.25), and officers (OR, 1.28; 95% CI, 1.18-1.37) were also more likely to be screened. Within an equal-access, universal health care system, black patients had higher rates of CRC screening in comparison with prior reports and even in comparison with white patients within the population. These findings highlight the need to understand and develop meaningful approaches for promoting more equitable access to preventative care. Moreover, equal-access, universal health insurance for both the military and civilian populations can be presumed to improve access for underserved minorities.

Protamine to expedite vascular hemostasis after catheter ablation of atrial fibrillation: A randomized controlled trial

There are no randomized controlled studies of the efficacy and safety of protamine to reverse anticoagulant effects of heparin after catheter ablation (CA) of atrial fibrillation (AF). The purpose of this study was to determine the efficacy and safety of protamine to expedite vascular hemostasis and ambulation after CA of AF. CA to eliminate AF (n = 139) or left atrial flutter (n=11) was performed in 150 patients using radiofrequency catheter ablation (n = 112) or cryoballoon ablation (n = 38). CA was performed under uninterrupted anticoagulation with warfarin in 28 patients or after skipping a single dose of a novel oral anticoagulant in 122 patients who were randomized to receive protamine (n= 77) or to the control group (n = 73). Baseline and procedural characteristics were similar between the 2 groups. Hemostasis was achieved manually once the activated clotting time returned to preprocedural values. The maximum activated clotting time during CA was 359± 31 and 359 ± 29 seconds in the protamine and control groups, respectively (P = .91). The time to hemostasis was 123± 95 minutes in the protamine group and 260 ± 70 minutes in the control group (P < .001). The time to ambulation was 316± 80 and 480 ± 92 minutes in the protamine and control groups, respectively (P < .001). There were no differences in the rates of major or minor vascular access complications or thromboembolic events (P > .05). Protamine expedites vascular hemostasis and time to ambulation by ∼3 hours after CA of AF without an increase in the risk of vascular or thromboembolic complications.