Cost of management of severe pneumonia in young children: systematic analysis.

BACKGROUND: Childhood pneumonia is a major cause of childhood illness and the second leading cause of child death globally. Understanding the costs associated with the management of childhood pneumonia is essential for resource allocation and priority setting for child health. METHODS: We conducted a systematic review to identify studies reporting data on the cost of management of pneumonia in children younger than 5 years old. We collected unpublished cost data on non-severe, severe and very severe pneumonia through collaboration with an international working group. We extracted data on cost per episode, duration of hospital stay and unit cost of interventions for the management of pneumonia. The mean (95% confidence interval, CI) and median (interquartile range, IQR) treatment costs were estimated and reported where appropriate. RESULTS: We identified 24 published studies eligible for inclusion and supplemented these with data from 10 unpublished studies. The 34 studies included in the cost analysis contained data on more than 95 000 children with pneumonia from both low- and-middle income countries (LMIC) and high-income countries (HIC) covering all 6 WHO regions. The total cost (per episode) for management of severe pneumonia was US$ 4.3 (95% CI 1.5-8.7), US$ 51.7 (95% CI 17.4-91.0) and US$ 242.7 (95% CI 153.6-341.4)-559.4 (95% CI 268.9-886.3) in community, out-patient facilities and different levels of hospital in-patient settings in LMIC. Direct medical cost for severe pneumonia in hospital inpatient settings was estimated to be 26.6%-115.8% of patients' monthly household income in LMIC. The mean direct non-medical cost and indirect cost for severe pneumonia management accounted for 0.5-31% of weekly household income. The mean length of stay (LOS) in hospital for children with severe pneumonia was 5.8 (IQR 5.3-6.4) and 7.7 (IQR 5.5-9.9) days in LMIC and HIC respectively for these children. CONCLUSION: This is the most comprehensive review to date of cost data from studies on the management of childhood pneumonia and these data should be helpful for health services planning and priority setting by national programmes and international agencies.

In patients undergoing video-assisted thoracic surgery for pleurodesis in primary spontaneous pneumothorax, how long should chest drains remain in place prior to safe removal and subsequent discharge from hospital?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was how long chest drains should be left in place following video-assisted thoracic surgery (VATS) pleurodesis for primary spontaneous pneumothorax. Altogether, a total of 730 papers were found using the reported search, of which eight represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We report that the main determining factor for the length of hospital stay following VATS pleurodesis is chest-drain duration. Providing no postoperative complications occur, and chest X-ray appearances of lung inflation are satisfactory, there is no documented contraindication to removing chest drains as early as 2 days postoperatively, with discharge the following day. Furthermore, leaving chest drains on water seal after a brief period of suction has been shown to benefit in reducing postoperative chest-drain duration and subsequent hospital stay. There is a paucity of literature directly addressing early vs late chest-drain removal protocols in this patient group. Hence, we conclude that, in clinical practice, the decision of when to remove chest drains postoperatively should remain guided empirically towards the individual patient.

Intra-operative localisation of spinal level using pre-operative CT-guided placement of a flexible hook-wire marker.

Confident intra-operative localisation of thoracic spinal pathology remains challenging. Several strategies are routinely employed, including intra-operative fluoroscopy and pre-operative image-guided skin marking. These techniques are limited both by potential inaccuracy and inconvenience. Here we present a novel, efficient and accurate technique for intra-operative localisation of thoracic spinal pathology using pre-operative CT-guided placement of a flexible hook-wire marker.