The Role of Multilevel Intercostal Nerve Block in Local Anesthetic Thoracoscopy.

BACKGROUND: Intercostal nerve block (ICNB) has long been used in thoracic surgery. Local anesthetic thoracoscopy (LAT) is performed under conscious sedation with local anesthesia at the port insertion site. This alone, however, does not anesthetize the parietal pleura from where biopsies are taken and patients can experience pain. OBJECTIVES: To compare LAT with multilevel ICNB versus standard care to determine whether it reduces pain during and post-LAT, its effect on analgesia use, the hospital length of stay (LOS), and related complications. METHODS: Prospective analysis of patients undergoing LAT between January and June 2021. In the ICNB group, levobupivacaine/xylocaine is administered at the angle of the rib immediately before LAT (up to 5 rib spaces). Visual Analog Score for pain (0 to 100 mm) was measured at 1 and 2 hours post-LAT and daily including analgesia use. RESULTS: Twenty patients (10 ICNB vs. 10 standard care group). The mean age is 68 years with 70% males. Visual Analog Score for pain in the ICNB group reduced by 55 mm at 1 and 2 hours post-LAT and 45 mm at day 1 ( P <0.05) (minimal clinically important difference >16 mm]. Median LOS was reduced by 50% in the ICNB group ( P <0.05). Paracetamol use reduced by 56% ( P <0.05). CONCLUSION: ICNB not only significantly reduces postprocedure pain but also reduces LOS.

Changes in lung cancer staging and emergency presentations during the first year of the COVID-19 pandemic.

Aim: This study retrospectively analyses the impact of the 1st year of the COVID-19 pandemic on route of presentation and staging in lung cancer compared to the 2 years before and after implementation of the Leicester Optimal Lung Cancer Pathway (LOLCP) in Leicester, United Kingdom. Method: Electronic databases and hospital records were used to identify all patients diagnosed with lung cancer in 2018 (pre-LOLCP), 2019 (post-LOLCP), and March 2020-2021 (post-COVID-19 lockdown). Information regarding patient characteristics, performance status, stage, and route of diagnosis was documented and analysed. Emergency presentation was defined as diagnosis of new lung cancer being made after unscheduled attendance to urgent or emergency care facility. Results: Following implementation of the LOLCP pathway, there was a significant decrease in emergency presentations from 26.8 to 19.6% (p = 0.002) with a stage shift from 33.9% early stage disease to 40.3%. These improved outcomes were annulled during the COVID-19 pandemic, with emergency presentations increasing to 38.9% (p < 0.001) and a reduction in early-stage lung cancer diagnoses to 31.5%. There was a 61% decline in 2 week wait referrals but no significant decline in the LOLCP direct-to-CT referrals. Conclusion: We have demonstrated a significant increase in late-stage lung cancer diagnoses and emergency presentations during the first year of the COVID-19 pandemic. The causes for these changes are likely to be multifactorial. The long-term effect on lung cancer mortality remains to be seen and is an important focus of future study.

Overview and knowledge of prosthodontic diagnostic aids among interns and post graduates - A cross-sectional questionnaire study.

Aim: This study aims to evaluate and compare the knowledge of prosthodontic diagnostic aids among interns and postgraduates. Settings and Design: A questionnaire survey was conducted to assess and compare the knowledge of prosthodontic diagnostic aids among interns and postgraduates. Based on the pilot study with alpha error 5% and a power of study 80%, the sample size was estimated to be 858 for each group. Materials and Methods: The self constructed questionnaire consisted of 3 sections, of which each section had 5 questions, a total of 15 questions validated by a team of 6 experts. The questionnaire was distributed electronically among interns and postgraduates in various dental colleges across India. Data were collected and subjected to statistical analysis. Statistical Analysis: All outcomes of this survey were analyzed using an independent t test. The Mann- Whitney test was used to determine the significance of two groups. Results: From the results obtained, it was found that interns (mean: 6.90; standard deviation: 2.442) had less knowledge regarding diagnostic tools than postgraduate students (mean: 8.76; standard deviation: 1.818). Conclusion: Diagnostic aids simplifies the process of diagnosis and treatment planning. Moreover, the knowledge of diagnostic aids among younger generation permits them to redefine the way dentistry is practiced and at the same time helps to provide better treatment results and achieve the utmost for the profession. Adequate knowledge of diagnostic aids is the need of the hour. Dental professionals should constantly update knowledge regarding various diagnostic aids in Prosthodontics, so as to arrive at optimum diagnosis and treatment plan with longer prognosis.

Subcutaneous Emphysema Risk Following Indwelling Pleural Catheter Insertion During Rigid Local Anesthetic Thoracoscopy: Via Thoracoscopy Port Versus Separate Incision Site.

BACKGROUND: Local anesthetic thoracoscopy (LAT) is important in the diagnosis of unilateral pleural effusions. Indwelling pleural catheters (IPC) can be inserted during LAT if a nonexpandable lung is suspected. Subcutaneous emphysema (SCE) is a known complication and is associated with increased morbidity and length of stay. It is unclear however if the incidence of SCE is affected if IPC is inserted through a separate incision to the LAT port. We aim to establish the incidence and grading of SCE when IPC is inserted during LAT and to determine if the site of IPC placement influences this. METHODS: Retrospective analysis of LAT electronic records and radiology images over 8 years in a University Hospital. The incidence of SCE was assessed during admission and follow-up with the severity of SCE graded 0 to 4 (0 none; 1 at IPC site; 2 ipsilateral chest wall; 3 ipsilateral neck; 4 contralateral chest wall). RESULTS: 55 combined LAT and IPC procedures were performed. In 28 patients the IPC was inserted through the LAT port and in 27 the IPC was inserted in a separate intercostal space (ICS) to the LAT port. On day zero, the incidence of any SCE was lower if the IPC was inserted using a separate ICS to the LAT port compared with the same site as the LAT port( P =0.01). This was similarly reduced on discharge chest radiographs and subsequent follow-up. CONCLUSION: IPC insertion at LAT using a separate ICS to the LAT port is associated with a reduction in the incidence of SCE during admission and follow-up.

The impact of the COVID-19 pandemic on pleural infection incidence: a UK multicentre retrospective analysis.

There was a significant reduction in pleural infection incidence, by almost a third, in the year following the start of the #COVID19 pandemic. Public health measures enforced during this period are likely to have played a significant role. https://bit.ly/3QAPPR9.

'Pleural Triage' facilitates effective management of a pleural service in the COVID-19 era.

The COVID-19 pandemic has created new challenges for management of pleural diseases. As resources and staff have been redirected to manage acutely unwell COVID-19 patients, routine medical practice and service provision for pleural diseases have been severely disrupted. We recognised the impact this had for patients with pleural diseases, who can be highly vulnerable to infection and often have conditions for which treatment cannot be safely delayed. The pleural service was reviewed in a tertiary centre, focusing on the changes that allowed maintenance of a service whilst maximising patient and staff safety, with the aim that these service transformations can be adopted elsewhere to improve care for pleural patients during and beyond COVID-19.

Modern day management of a unilateral pleural effusion.

Over 50 systemic conditions may affect the pleura and, thus, unilateral pleural effusions may present for a variety of reasons. Investigating the cause is essential to providing appropriate management. Various pleural interventions are available in current practice, but have varying diagnostic sensitivity. It is, therefore, vital to consider the intervention with the highest diagnostic yield appropriate to the particular clinical situation. The diagnostic pathway in unilateral pleural effusion is increasingly outpatient based, avoiding hospitalisation, which is particularly relevant with the recent COVID-19 pandemic.

Vertebral fracture assessment in patients presenting with a non-hip non-vertebral fragility fracture: experience of a UK Fracture Liaison Service.

Twenty-five percent of patients with a non-hip non-vertebral fragility fracture have an undiagnosed vertebral fracture detected by vertebral fracture assessment during bone densitometric assessment. The prevalence of an undiagnosed vertebral fracture is higher in older people, and they are more likely to have multiple vertebral fractures. PURPOSE: Most vertebral fragility fractures (VFF) have no history of trauma. Vertebral fracture assessment (VFA) during dual energy x-ray absorptiometry (DXA) can be used to detect these VFFs. This study aims to identify the prevalence of undiagnosed VFF in patients presenting with a non-hip non-vertebral fragility fracture. METHODS: Patients identified by the fracture liaison service (FLS) of a large UK university hospital presenting with a non-hip non-vertebral fragility fracture were evaluated from 1 January 2012 to 30 September 2015. Local protocol identified those that would proceed for VFA. Data was collected on patient characteristics, fracture details, bone mineral density (BMD) measurements and VFA results. RESULTS: Five hundred sixty-seven patients (mean (SD) age, 72 (9.4) years) of mostly women (88.3%) had a VFA performed as part of their DXA assessment. One hundred forty-three patients (25.2%) were identified to have a vertebral fracture, of whom 57.3% of them had one fracture. 49.5% of those with vertebral fractures had BMD measurements diagnostic of osteoporosis. Mean (SD) age was higher in those with vertebral fractures compared to those without; 74.9 (8.3) years vs 70.4 (9.5) years, p < 0.00. Those aged 75 years and over were more likely to have multiple fractures than those younger than 75 years (16.3 vs 4%, p = 0.01). CONCLUSION: A quarter of patients presenting with a non-hip non-vertebral fragility fracture have an undiagnosed vertebral fracture. Older people are more likely to have vertebral fractures and more likely to have multiple fractures. VFA during bone densitometric assessment can further aid stratifying future fracture risk.