Perioperative Transthoracic Lung Ultrasound for Assessment of Pulmonary Outcome in Adolescent Idiopathic Scoliosis Patients: Prospective, Observational Pilot Study.

The purpose of study was to evaluate the perioperative lung ultrasound findings of patients undergoing scoliosis correction. LUS examination was performed examined three 3 times for each patient: 20 min after starting mechanical ventilation of the lungs(preoperative), after surgery when the patient was placed in the supine position(postoperative), and 20 min after arrival in the post-anaesthesia care unit. Arterial blood gas analyses, mechanical ventilation parameters, peripheral oxygen saturation(SpO2) were also checked. Twenty-six patients completed the study. The changes of LUS score(20 min) was significantly negatively correlated with the partial pressure of arterial oxygen(PaO2)/fraction of inspired oxygen(FiO2) ratio change(P = 0.039, r = -0.40). The change in mean convex side LUS score was significantly greater than that of the concave side as determined by two-factor repeated measures analysis of variance(p = 0.001). Multiple regression analysis revealed perioperative LUS change was the significant factor related to the oxygen index change (p = 0.042). One case of pneumothorax was diagnosed and pleural thickening more than 5 mm was detected in 8 patients and five patients of those were diagnosed pleural effusion and performed thoracentesis after surgery. Postoperative increase of LUS score was related with deteriorating of oxygenation at one day after surgery, and it suggests that lung ultrasound allows prediction of postoperative hypoxia and facilitates the diagnosis of pulmonary complications at operation room in AIS patients.

Cost-effectiveness of hydrogel plugs in CT-guided lung biopsies. / Estudio de coste-efectividad sobre la utilización de un tapón de hidrogel en las biopsias pulmonares guiadas por tomografía computarizada.

OBJECTIVE: Using a hydrogel plug decreases the number of cases of pneumothorax and reduces the need for pleural drainage tubes in CT-guided lung biopsies. We aimed to analyze the cost-effectiveness of using hydrogel plugs. MATERIAL AND METHODS: We analyzed 171 lung biopsies divided into three groups: Group 1 (n=22): fine-needle aspiration cytology (FNAC) without hydrogel plugs; Group 2 (n=89): FNAC with hydrogel plugs; and Group 3 (n=60): FNAC plus core-needle biopsy (CNB) with hydrogel plugs. We calculated the total costs (direct and indirect) in the three groups. We analyzed the percentage of correct diagnoses, the average and incremental rations, and the most cost-effective option. RESULTS: Total costs: Group 1 = 1,261.28 + 52.65 = € 1,313.93; Group 2 = 1,201.36 + 67.25 = € 1,268.61; Group 3 = 1,220.22 + 47.20 = € 1,267.42. Percentage of correct diagnoses: Group 1 = 77.3%, Group 2 = 85.4%, and Group 3 = 95% (p = 0.04). Average cost-effectiveness ratio: Group 1 = 16.99; Group 2 = 14.85; and Group 3 = 13.34. CONCLUSIONS: Group 3 was the best option, with the lowest average cost-effectiveness ratio; therefore, the most cost-effective approach is to do FNAC and CNB using a dehydrated hydrogel plug at the end of the procedure.

CORTRAK Superuser Competency Assessment and Training Recommendations.

BACKGROUND: Blind insertion of feeding tubes remains unsafe. Electromagnetic placement devices such as the CORTRAK Enteral Access System allow operators to interpret placement of feeding tubes in real time. However, pneumothoraces have been reported and inadequate user expertise is a concern. OBJECTIVE: To explore factors influencing competency of CORTRAK-assisted feeding tube insertion. METHODS: A prospective, observational pilot study was conducted. Data collection included demographics, self-confidence, clinical judgment regarding CORTRAK-assisted feeding tube insertion, and general self-efficacy. CORTRAK-assisted feeding tube insertions were performed with the Anatomical Box and CORMAN task trainers. RESULTS: Twenty nurses who had inserted a mean of 53 CORTRAK feeding tubes participated. Participants inserted a mean of 2 CORTRAK feeding tubes weekly; each had inserted a feeding tube in the past 7 days. All superusers were competent; 1 required remediation for improper receiver unit placement. Mean (SD) scores were 35 (3.68) on a 40-point scale for self-efficacy, 4.6 (0.68) on a 5-point scale for self-reported feeding tube insertion confidence, and 4.85 (0.49) on a 5-point scale for demonstrated confidence. Participants estimated that 8 CORTRAK-assisted insertions were needed before they felt competent as super users. Confidence with the CORTRAK tracing was estimated to require 10 feeding tube insertions. Six participants continued to assess placement by auscultation, suggesting low confidence in their interpretation of the tracing. CONCLUSIONS: At least 3 observations should be performed to assess initial competency; the number should be individualized to the operator. Interpretation of the insertion tracing is complex and requires multiple performance opportunities to gain competency and confidence for this high-risk skill.

Medical and Economic Evaluation of FOREseal Bioabsorbable Reinforcement Sleeves Compared With Current Standard of Care for Reducing Air Leakage Duration After Lung Resection for Malignancy: A Randomized Trial.

OBJECTIVE: The objective of this study was to determine the efficacy of alginate staple-line reinforcement of fissure openings as compared with stapling alone, with or without tissue sealant or glue, in reducing the incidence and duration of air leakage after pulmonary lobectomy for malignancy. SUMMARY BACKGROUND DATA: No randomized trial evaluating alginate staple-line reinforcement has been performed to date. METHODS: The Staple-line Reinforcement for Prevention of Pulmonary Air Leakage study was a multicenter randomized trial, with blinded evaluation of endpoints. Patients over 18 years of age scheduled for elective open lobectomy or bilobectomy for malignancy were eligible for enrollment. At thoracotomy, patients were deemed ineligible if an unanticipated pneumonectomy was indicated, or if air leakage occurred after the liberation of pleural adhesions. Otherwise, if the fissure was incomplete or the lung had an emphysematous appearance, patients were randomized to either standard management or interventional procedure consisting of fissure opening with linear cutting staplers buttressed with paired alginate sleeves (FOREseal). The number of eligible patients necessary in each randomization arm was estimated to be 190, and an outcomes analysis was performed on an intention-to-treat basis. RESULTS: Of the 611 patients consented to study enrollment, 380 met the inclusion criteria and were randomized. Based on an intention-to-treat analysis, the primary endpoint of air leak duration was not different between the 2 groups: 1 day (range: 0-2 d) in the FOREseal group and 1 day (range: 0-3 d) in the control group (P = 0.8357). In addition, the 2 groups were similar in terms of the proportion of patients presenting with prolonged air leakage (7.8% in the FOREseal group vs 11.3% in the control group, P = 0.264) and the average duration of chest drainage (P = 0.107). Procedure costs were comparable for both groups. CONCLUSIONS: FOREseal did not demonstrate a significant advantage over standard treatment alone.

Utilization of the track embolization technique to improve the safety of percutaneous lung biopsy and/or fiducial marker placement.

PURPOSE: The purpose of the study was to describe and present outcomes of the track embolization technique with absorbable hemostat gelatin powder during percutaneous computed tomography (CT)-guided lung biopsy and/or fiducial marker placement versus the standard of care (no track embolization) in an attempt to decrease rates of pneumothorax (PTX), chest tube placement, hemorrhage and/or complications, and average cost per patient. MATERIALS AND METHODS: An institutional review board-approved, case-control, retrospective study was performed in which 125 consecutive patients who underwent track embolization were compared with 124 consecutive controls at one institution. For subjects in whom the track embolization technique was utilized, it was performed passively through a coaxial needle as it was removed. All procedures were performed by one of three attending interventional radiologists. For each group, medical records and procedure images were reviewed for PTX occurring postprocedure, PTX requiring chest tube placement, and occurrence of minor or major complication and/or hemorrhage. Comparison was made with published complication rates, and a cost-per-patient analysis was performed. Statistical analysis was performed utilizing Fisher's Exact Test. RESULTS: In track embolization cases versus controls, there were statistically significant reduction in PTX (8.8% vs. 21%; P=.007) and reduction in PTX requiring chest tube placement (4% vs. 8.1%; P=.195). This compares favorably to previously published rates of PTX and chest tube placement of 8%-64% and 1.6%-17%, respectively. None of the pneumothoraces occurring at time of needle placement increased in size with use of the track embolization technique. There were no major complications (including neurological sequela) in the track embolization group. In track embolization cases versus controls, there was a statistically significant reduction in both the rate of major hemorrhage (0% vs. 4%; P=.029) and average cost per patient ($262.40 vs. $352.07; P=.044). CONCLUSIONS: CT-guided percutaneous lung biopsy and/or fiducial marker placement were safer utilizing the track embolization technique during trocar removal. In addition, this technique was cost effective in the study population.

Staplers versus hand-sewing for pulmonary lobectomy: randomized controlled trial.

BACKGROUND: Division of the parenchymal lung for lobectomy is performed in patients who have an incomplete fissure. A stapler device can reduce postoperative air leak, but it is expensive. OBJECTIVE: to investigate the advantage of using a stapler, in terms of postoperative air leak and cost, compared to hand-sewn techniques. METHOD: A Non-blinded randomized controlled trial was conducted in Chiang Mai University Hospital, Thailand, from November 15, 2011 to September 30, 2012. Fifty-three adult patients were randomized to undergo a hand-sewn technique (27 patients) or stapler closure (26 patients). RESULTS: Postoperative air leak in the stapler group was less than that in the hand-sewn group (7.7% vs. 29.6%, p = 0.044), and the duration of air leak in the stapler group was significantly shorter than that in the hand-sewn group (1.0 vs. 13.4 days, p = 0.032). The cost of treatment was not significantly different between groups; however, the total cost in the stapler group was less than that in the hand-sewn group (mean difference 4454 Thai baht (US$144.75). CONCLUSION: A stapler reduces postoperative air leaks and the duration of air leaks. Furthermore, the total cost of treatment was comparable. Therefore, using staples may provide substantial financial benefits.

Large animal-related injury requiring hospital admission: injury pattern disparities.

BACKGROUND: Due to the infrequent occurrence of large animal-related injury (LARI) in many areas, their significance as a public health problem could be overlooked. The purpose of this study was to examine the demographics and injury disparities associated with LARI. METHODS: The Healthcare Cost and Utilization Project Nationwide Inpatient Survey from 2001 was used to construct a cohort of patients admitted after LARI. Patients were stratified by age, gender, race, and median household income of patient's zip code. Where available total hospital charges were converted to cost using the hospital's cost-to-charge ratio. To determine variables associated with injury type, univariable and multivariable logistic regression analysis were used. RESULTS: 2424 LARI admissions were identified within the database. The largest proportion of admitted patients were female (53.8%), Caucasian (64.6%), and from areas with median income >$45,000 (41.8%). Average hospital cost was $5062. Overall, the most common injuries were rib fractures (15.2%), vertebral fractures (11.6%) and haemo-pneumothorax (9%). Multivariable logistic regression analysis revealed that age disparities with older patients receiving more rib fractures, haemo-pneumothorax, vertebral fractures, and pelvic fractures. Skull fractures and head injuries are disproportionately seen in younger patients. Gender disparities were also present, with females more likely to have vertebral fractures but less likely to have rib fractures and heart and lung injuries. CONCLUSIONS: Disparities based on age and gender are associated with hospital admission for LARI in the United States. These admissions have a significant impact on the healthcare system with nationwide cost estimates of nearly $60 million. These findings represent potential areas for targeted prevention efforts.

Ultrasound-guided central line placement as compared with standard landmark technique: some unpleasant arithmetic for the economics of medical innovation.

OBJECTIVE: We perform a simple cost estimation of ultrasound guidance for the placement of central venous access, considering the US federal reimbursement for ultrasound guidance of central line placement to the federal reimbursement for treating the complication of pneumothorax. METHODS: We utilize national statistics on the number of central lines placed annually to determine the cost savings incurred if all central lines placed in the United States were placed with ultrasound guidance. RESULTS: The initial "cost" of placing central lines was found to be 390,780,000 to 651,300,000 dollars per year by the landmark technique, as compared with 494,820,000 to 824,700,000 dollars per year by ultrasound guidance. CONCLUSIONS: The cost of ultrasound guidance was not mitigated by its reduction in the cost of treating pneumothoraces.

Pressure characteristics of mechanical ventilation and incidence of pneumothorax before and after the implementation of protective lung strategies in the management of pediatric patients with severe ARDS.

OBJECTIVE: To compare pressure characteristics of mechanical ventilation and their impact on pediatric patients with severe ARDS in the pre-protective lung strategy (PLS) and post-PLS eras. METHODS: Medical records of 33 patients admitted to our pediatric ICU with ARDS from 1992 through 1994 (pre-PLS) and 52 patients with ARDS admitted from 2000 through 2003 (post-PLS) were retrospectively reviewed. RESULTS: Patient age and gender distribution were identical in both eras. Fifty-five percent of the patients in the pre-PLS era had pneumothorax, compared to 17% in the post-PLS era (p < 0.05). Overall mortality rates for patients in the pre-PLS and post-PLS eras were 42% and 25%, respectively (p = 0.09; not significant). Mean duration of exposure to peak inspiratory pressure (PIP) values > 40 cm H2O was significantly longer in the pre-PLS era than in the post-PLS era. Pre-PLS patients with pneumothorax received mean maximum PIP of 72 +/- 17 cm H2O, mean maximum positive end-expiratory pressure (PEEP) of 20 +/- 5 cm H2O, and maximum mean airway pressure (MAP) of 46 +/- 8 cm H2O, while patients in the post-PLS era required mean maximum PIP of 42 +/- 2 cm H2O, mean maximum PEEP of 14 +/- 2 cm H2O, and maximum MAP of 30 +/- 6 cm H2O, respectively (p < 0.05 for all pressure parameters). There were no significant differences in mechanical ventilation pressure characteristics among patients who did not have pneumothorax during their course of management in both eras. CONCLUSIONS: A significantly more aggressive use of ventilator pressure characteristics distinguished the pre-PLS era from the post-PLS era, and was found to be associated with a markedly higher incidence of pneumothorax. Outcome in both eras did not differ significantly, presumably due to insufficient statistical power.

Chest radiograph after central line placement under fluoroscopy: utility or futility?

BACKGROUND: Postoperative portable chest films are routinely performed after fluoroscopic placement of central venous catheters to evaluate positioning and to rule out significant complications (eg, pneumothorax). Emerging evidence in the literature has called this practice into question suggesting that routine postoperative chest x-ray is unnecessary. Therefore, we investigated our recent experience to examine the utility of these films, to examine the development of symptoms relative to therapeutic intervention, and to report a cost-benefit analysis. METHODS: After obtaining institutional review board approval, all charts of patients undergoing central venous catheter placement from January 2004 to December 2005 at our institution were reviewed. Outcome measures included whether or not there was a complication and whether or not that complication required an intervention. Peripherally inserted central catheters were not included. RESULTS: In the study population, 237 catheters were placed in the operating room. There were two complications, both pneumothoraces (0.085%). One patient required tube thoracostomy, whereas the other was asymptomatic and the pneumothorax resolved spontaneously. Fourteen patients had no postoperative chest film without adverse consequences. Total cost for portable chest films was $56,196. CONCLUSIONS: For catheters placed under fluoroscopic guidance, postoperative chest films in asymptomatic patients add unnecessary cost. For this reason, we feel discontinuation of postoperative chest films in asymptomatic patients undergoing catheter placement with fluoroscopy is justifiable.

Do the benefits of shorter hospital stay associated with the use of fleece-bound sealing outweigh the cost of the materials?

OBJECTIVES: To compare the cost of materials and hospitalization for standard techniques (suturing, stapling and electrocautery) for sealing the lung after pulmonary resection with those for a fleece-bound sealing procedure. METHODS: This cost comparison analysis uses as its basis a prospective randomised clinical trial involving 152 patients with pulmonary lobectomy/segmentectomy (standard technique group: 77 patients; fleece-bound sealing group: 75 patients). The cost comparison was performed from the economic perspective of Austrian and German hospitals, taking into consideration the cost of materials for the two alternatives as well as the mean time to hospital discharge. RESULTS: The clinical study found significantly smaller postoperative air leaks in the fleece-bound sealing group. The mean times to chest drain removal and to hospital discharge were also significantly reduced after application of fleece-bound sealing [5.1 vs. 6.3 days (P=0.022) and 6.2 vs. 7.7 days (P=0.01), respectively]. The cost of materials for sealing air leaks amounted to euro47 per patient in the standard technique group and euro410 per patient in the fleece-bound sealing group. The 1.5-day reduction in the length of hospital stay associated with fleece-bound sealing represents a saving of euro462 per patient. CONCLUSIONS: There was an overall saving of euro99 for the fleece-bound sealing procedure compared to standard techniques for sealing the lung following pulmonary resection.

[Diagnostic percutaneous thoracic punctures. Assessment through a critical study of a compliation of 2406 cases]. / Ponctions thoraciques percutanées à visée diagnostique. Mise au point à partir de l'étude critique d'une expérience de 2406 cas.

The aim of this retrospective study of 2,406 diagnostic percutaneous thoracic needle aspirations under computer tomographic control was to assess the diagnostic value of this method, the technical problems and the complications and finally, to refine the indications. Percutaneous needle aspiration had been carried out after negative fibreoptic bronchoscopy. The authors review their technique and show the value of biopsy material which is only slightly traumatised. Computerised tomography and fine needle aspiration reduce the risk of pneumothorax and haemorrhage in a significant fashion. Personalized collaboration between the radiologist, physician and cytologist is a vital pre-requisite. The indications are discussed notably in cases of solitary pulmonary nodules and of mediastinal masses.

[Pleural drainage vs video-assisted minimally invasive surgery in the treatment of spontaneous pneumothorax. A retrospective study]. / Drenaggio pleurico vs chirurgia mini-invasiva videoassistita nel trattamento del pneumotorace spontaneo. Studio retrospettivo.

The most frequent cause of spontaneous pneumothorax is bleb's disease of the lung. Considering that, pnx s. has a remarkable bent for relapsing, we think that it's necessary an aggressive treatment to resolve it. That's because pleural drainage is useful for a symptomatic resolution, VATS for an etiologycal one. To value the real efficacy of the treatment of VATS, we have effected a retrospective research between two classes of patients suffering from pnx s. admitted in our Institute from 1987 until 1991, one treated with pleural drainage (class A, 11 patients) and the other with VATS (class B, 13 patients). 1) Patients treated with pleural drainage were nearly double compared to class B. 2) In class A, the mean value of drainages were nearly double compared to class B. 3) Class A had a number of relapses 10 times more compared to B. 4) Considering the period of hospitalization, class A had a value nearly triple compared to B. 5) We've noticed that the mean value of the cost for episode of pnx s. in class A was more than 15% compared to class B and the cost for patient in class A was nearly double than in class B. We can affirm that, for the treatment of pnx s., the method of VATS rappresents a real success. We're passed from the "symptomatological treatment" of it to an aetiological one, joined to the prophylaxis of the relapse.