Preliminary Evaluation of a Novel Neural Network-Based Hybrid Simulator for Surgical Training and Performance Assessment of Neonatal Thoracentesis.

INTRODUCTION: Tension pneumothorax is a rare and life-threatening situation in neonates requiring immediate intervention through thoracentesis. Significant complications can arise while performing thoracentesis in the case of inadequate skill level or exposure to the condition. Although simulation-based training (SBT) has proven to be effective in learning surgical skills, training sessions are long, subjective, and expensive, because of which they cannot be held regularly. This article attempts to improve traditional SBT for neonatal thoracentesis through an autonomous simulator that can provide real-time objective feedback during surgical training and assessment. METHODS: The simulator incorporates a custom manikin and virtual reality software interfaced through electromagnetic sensors that track the motion of surgical instruments. The software application reads and stores instrument motion information to replicate physical actions in the virtual environment, play back previously stored surgical performances and analyze data through a pretrained neural network. The simulator encapsulates the experience of SBT by allowing trainees to watch and replicate an ideal method of conducting the procedure, providing simplified, real-time autonomous guidance during practice and an objective taskwise assessment of the performance during testing. RESULTS: The preliminary trial held at the University of Illinois Hospital in the presence of 1 neonatologist and 4 fellows revealed that all the participants used the autonomous guidance more than once, and all found simulation experience to be accurate and overall effective in learning thoracentesis. CONCLUSION: Although the sample size is small, the simulator shows potential in being a viable alternative approach for training and assessment for thoracentesis.

Growth in Thoracentesis and Paracentesis Performed by Radiology and Advanced Practice Providers: Medicare Volume and Reimbursement Trends From 2012 to 2018.

PURPOSE: To study trends in volume and reimbursement for paracentesis and thoracentesis by physicians and advanced practice providers (APPs) after the introduction of discreet Current Procedural Terminology codes for image guidance. METHODS: Medicare claims for 2012 to 2018 (paracentesis) and 2013 to 2018 (thoracentesis) were extracted using Current Procedural Terminology codes for blind and image-guided paracentesis and thoracentesis. Total volumes were analyzed by provider specialty. Nonfacility reimbursement and relative value units were compared. RESULTS: For blind paracentesis, volume decreased from 17,393 to 12,226 procedures from 2012 to 2018. Conversely, volume of image-guided paracentesis increased from 171,631 to 253,834 procedures. Radiology performed the majority of image-guide paracentesis (83.9% in 2012 and 77.1% in 2018). Volume and relative share for APPs dramatically increased (from 10.2% to 15.8%). For blind thoracentesis, volume decreased from 26,716 to 15,075 procedures from 2013 to 2018. Conversely, volume of image-guided thoracentesis increased from 187,168 to 222,673 procedures. Radiology performed the majority of image-guided thoracentesis (73.6% in 2013 and 66.2% in 2018). Volume and relative share for APPs dramatically increased (from 7.7% to 12.9%). Although reimbursement for both image-guided paracentesis and thoracentesis decreased, their reimbursement remained higher than that of blind paracentesis and thoracentesis throughout the study period. CONCLUSION: A higher percentage of these procedures are being performed using image guidance; radiologists performed a growing number but declining percentage of image-guided paracentesis and thoracentesis. APPs are playing an increasing role, particularly using image guidance. Given decreasing reimbursement for these procedures, APPs can provide a large cost advantage in procedural radiology practices.

Outcomes of Thoracentesis for Acute Heart Failure in Hospitals.

Data on in-hospital outcomes for hospitalizations undergoing thoracentesis (THR) for any cause has been conflicting. For hospitalizations with acute heart failure (HF), however, to date, no study has evaluated the outcomes of THR. Accordingly, our current study addresses this knowledge gap. We analyzed data from the Nationwide Inpatient Sample (2005-14). The study population included all adults (>18 years) with the principal discharge diagnosis of HF and the presence of procedure code for THR. Hospitalizations with pneumonia, acute kidney injury, and co-morbidities such as malignancy, lymphoma, liver disease, end-stage renal disease, metastatic disease, and tuberculosis were excluded. Propensity matching was performed to identify a similar cohort of admissions that did not undergo THR. Primary outcome of interest was in-hospital mortality and length of hospitalization. During the study period, 2,251,927 hospitalizations for HF were found from the database; of which, 70,823 (3.14%) had THR. After propensity matching, a matched cohort of 70,785 hospitalizations for HF was identified. In-hospital mortality was higher for those who underwent THR (2.5% vs 1.6%; p <0.001). In-hospital complications and procedures including cardiac arrest, sepsis, pneumothorax and hemothorax were more frequent in the THR group. Those who underwent THR had a longer mean length of stay (6.9 vs 4.5 days; p <0.01) and higher cost of hospitalization ($13,448 vs $ 8940; p <0.01). The trend analysis demonstrated a steady increase in the performance of THR in hospitalized HF between 2005 and 2014. In conclusion, THR performed during HF hospitalizations were associated with higher rates of in-hospital mortality, complications and increased healthcare utilization in the form of longer length of stay and higher costs.

Healthcare Costs and Utilization among Patients Hospitalized for Malignant Pleural Effusion.

BACKGROUND: Malignant pleural effusion (MPE) poses a considerable healthcare burden, but little is known about trends in directly attributable hospital utilization. OBJECTIVE: We aimed to study national trends in healthcare utilization and outcomes among hospitalized MPE patients. METHODS: We analyzed adult hospitalizations attributable to MPE using the Healthcare Cost and Utilization Project - National Inpatient Sample (HCUP-NIS) databases from 2004, 2009, and 2014. Cases were included if MPE was coded as the principal admission diagnosis or if unspecified pleural effusion was coded as the principal admission diagnosis in the setting of metastatic cancer. Annual hospitalizations were estimated for the entire US hospital population using discharge weights. Length of stay (LOS), hospital charges, and hospital mortality were also estimated. RESULTS: We analyzed 92,034 hospital discharges spanning a decade (2004-2014). Yearly hospitalizations steadily decreased from 38,865 to 23,965 during this time frame, the mean LOS decreased from 7.7 to 6.3 days, and the adjusted hospital mortality decreased from 7.9 to 4.5% (p = 0.00 for all trend analyses). The number of pleurodesis procedures also decreased over time (p = 0.00). The mean inflation-adjusted charge per hospitalization rose from USD 41,252 to USD 56,951, but fewer hospitalizations drove the total annual charges down from USD 1.51 billion to USD 1.37 billion (p = 0.00 for both analyses). CONCLUSIONS: The burden of hospital-based resource utilization associated with MPE has decreased over time, with a reduction in attributable hospitalizations by one third in the span of 1 decade. Correspondingly, the number of inpatient pleurodesis procedures has decreased during this time frame.

Low-cost thoracentesis simulation for nurse practitioner students.

The fast-paced hospital setting is not routinely a conducive environment for practicing procedural skills. Simulation learning can provide an opportunity for learners to achieve accuracy, confidence, and competence when performing the thoracentesis procedure. The cost associated with many commercial-brand manikins and the additional supplies needed to teach thoracentesis is expensive. However, thoracentesis is a skill many nurse practitioners (NPs) need to learn. The use of a whole, unstuffed turkey purchased at a supermarket to simulate a thoracentesis is a way in which NP students can safely practice this skill. Nurse practitioner students perform assessment skills on another student, whereas students perform the thoracentesis procedure on this turkey carcass. Nurse educators can teach NP students to safely, accurately, and efficiently perform a thoracentesis procedure using a low-cost simulator. Nurse educators can teach NP students how to perform a thoracentesis using a turkey carcass at a relatively low cost with a high yield.

Early Readmission to Hospital in Patients With Cancer With Malignant Pleural Effusions: Analysis of the Nationwide Readmissions Database.

BACKGROUND: Hospital readmissions are costly to health-care systems and represent a measure of quality care. Patients with cancer with malignant pleural effusions (MPEs) are at high risk for rehospitalization; however, risk factors for readmissions in this population are not well described. Understanding the incidence and risk factors for readmission could facilitate the development of a readmission reduction strategy in this patient population. METHODS: We conducted a retrospective cohort study using the Nationwide Readmissions Database (NRD) (2014 sample) to determine the proportion of all-cause, unplanned, 30-day readmissions to hospital among patients with MPEs. Survey weighting methods that accounted for the NRD sampling design were used to generate nationally representative estimates. We used multivariable logistic regression to determine predictors of early readmission. RESULTS: There were 27,900 unplanned readmissions after 108,824 index hospitalizations for MPEs, a rate of 25.6% (95% CI, 25.0%-26.3%). The mortality rate during readmission to hospital was 17.3% (n = 4,840; 95% CI, 16.6%-18.1%). Mean cost per readmission was $15,452 ± $415, with total aggregate costs of > $400 million. Predictors of early readmission included having Medicaid insurance status, treatment with thoracentesis only, and discharge to a care facility or home health care. CONCLUSIONS: One in four patients with cancer and MPEs are readmitted to hospital within 30 days of discharge, and nearly one in five die during the readmission. Nondefinitive management with thoracentesis led to more readmissions. A further understanding of factors that drive preventable readmissions could significantly improve quality of care in this population.

Management of hepatic hydrothorax and effect on length of stay, mortality, cost, and 30-day hospital readmission.

BACKGROUND AND AIM: Cirrhosis-related complications are associated with high inpatient mortality, cost, and length of stay. There is a lack of multi-centered studies on interventions for hepatic hydrothorax and its impact on patient outcomes. The aim of this study was to determine the effect of performing thoracentesis for hepatic hydrothorax on hospital length of stay, mortality, cost, and 30-day readmission. METHODS: A retrospective analysis of the Nationwide Inpatient Sample between 2002 and 2013 and Nationwide Readmission Database during 2013 was performed including patients with a primary diagnosis of hydrothorax or pleural effusion and a secondary diagnosis of cirrhosis based on International Classification of Disease 9 codes. Univariate and multivariate analyses were performed to determine the effect of thoracentesis on patient outcomes during their hospital stay. RESULTS: Of the 37 443 patients included from the Nationwide Inpatient Sample, 26 889 (72%) patients underwent thoracentesis. Thoracentesis was associated with a longer length of stay (4.56 days, 95% confidence interval [CI]: 2.40-6.72) and higher total cost ($9449, 95% CI: 3706-15 191). There was no significant difference in inpatient mortality between patients who underwent thoracentesis compared with those who did not. Of the 2371 patients included from the Nationwide Readmission Database, 870 (33%) were readmitted within 30 days. Thoracentesis was not a predictor of readmission; however, transjugular intrahepatic portosystemic shunt (odds ratio: 4.89, 95% CI: 1.17-20.39) and length of stay (odds ratio: 1.02, 95% CI: 1.001-1.05) on index admission were predictors of readmission. CONCLUSION: When considering treatment for hepatic hydrothorax, many factors should contribute to determining the best intervention. While performing thoracentesis may provide immediate relief to symptomatic patients, it should not be considered a long-term intervention given that it increases hospital cost, was associated with longer length of stays, and did not improve mortality.

Assessment of Diaphragm Function and Pleural Pressures During Thoracentesis.

BACKGROUND: This prospective observational study reports on diaphragm excursion, velocity of diaphragm contraction, and changes in pleural pressure that occur with thoracentesis. METHODS: Twenty-eight patients with pleural effusion underwent therapeutic thoracentesis. Diaphragm excursion and velocity of diaphragm contraction were measured with M-mode ultrasonography of the affected hemidiaphragm. Pleural pressure was measured at each aliquot of 250 mL of fluid removal. Fluid removal was continued until no more fluid could be withdrawn, unless there was evidence of nonexpandable lung defined as a pleural elastance greater > 14.5 cm H2O/L and/or ipsilateral anterior chest discomfort. RESULTS: Twenty-three patients had expandable lung, and five patients had nonexpandable lung. Velocity of diaphragm contraction (mean ± SD) increased from 1.5 ± 0.4 cm/s to 2.8 ± 0.4 cm/s pre-thoracentesis and post-thoracentesis, respectively (CI, 0.93-1.61; P < .001) in subjects with expandable lung. Velocity of diaphragm contraction (mean ± SD) increased from 2.0 ± 0.4 cm/s to 2.3 ± 0.4 cm/s pre-thoracentesis and post-thoracentesis (P = .45) in subjects with nonexpandable lung. Diaphragm excursion was significantly increased in subjects with expandable lung at the end of thoracentesis; diaphragm excursion did not increase to a significant extent in patients with nonexpandable lung. CONCLUSIONS: The velocity of diaphragm contraction and diaphragm excursion increased in association with fluid removal with thoracentesis in patients with expandable lung, whereas it did not significantly change in patients with nonexpandable lung. This may derive from improvement in loading conditions of the diaphragm in patients with expandable lung related to its preload and length-tension characteristics.

Management of Malignant Pleural Effusions-What Is New.

Malignant pleural effusion (MPE) is a common and challenging problem. Patients affected by MPE have a poor prognosis and suffer from breathlessness and impaired quality of life. The management of MPE has barely changed for many decades; however, recent research has driven new paradigms in the diagnosis and treatment of MPE and stimulated novel concepts that are being evaluated in many ongoing studies. This review provides an overview of recent advances in the diagnosis of MPE, including new cytopathology and imaging techniques, and the landmark studies that provide a solid evidence base to support the use of indwelling pleural catheters as first-line treatment in MPE. Lingering management dilemmas, including optimal chest drainage tube and role of surgery in MPE, and key knowledge gaps that are the focus of ongoing research are also highlighted.

Disparities over Time in Volume, Day of the Week, and Patient Complexity between Paracentesis and Thoracentesis Procedures Performed by Radiologists versus Those Performed by Nonradiologists.

PURPOSE: To compare the disparities between the paracenteses and thoracenteses performed by radiologists with those performed by nonradiologists over time. Variables included the volume of procedures, the days of the week, and the complexity of the patient's condition. MATERIALS AND METHODS: Using carrier claims files for a 5% national sample of Medicare beneficiaries from 2004 to 2016, paracentesis and thoracentesis examinations were retrospectively classified by physician specialty (radiologist vs nonradiologist), day of the week (weekday vs weekend), and the complexity of the patient's condition (using Charlson comorbidity index scores). The Pearson chi-square and independent samples t-test were used for statistical analysis. RESULTS: Between 2004 and 2016, the proportion of all paracentesis and thoracentesis procedures performed by radiologists increased from 70% to 80% and from 47% to 66%, respectively. Although radiologists increasingly performed more of both services on both weekends and weekdays, the share performed by radiologists was lower on weekends. For most of the first 9 years across the study period, radiologists performed paracentesis in patients with more complex conditions than those treated by nonradiologists, but the complexity of patients' conditions was similar during recent years. For thoracentesis, the complexity of patients' conditions was similar for both specialty groups across the study period. CONCLUSIONS: The proportion of paracentesis and thoracentesis procedures performed in Medicare beneficiaries by radiologists continues to increase, with radiologists increasingly performing most of both services on weekends. Nonetheless, radiologists perform disproportionately more on weekdays than on weekends. Presently, radiologists and nonradiologists perform paracentesis and thoracentesis procedures in patients with similarly complex conditions. These interspecialty differences in timing and complexity of the patient's condition differ from those recently described for several diagnostic imaging services, reflecting the unique clinical and referral patterns for invasive versus diagnostic imaging services.

The Role of Ultrasound-Guided Therapeutic Thoracentesis in an Outpatient Transitional Care Program: A Case Series.

BACKGROUND: Symptomatic pleural effusions create discomfort and are a frequent cause of hospitalization. Ultrasound-guided thoracentesis is a key palliative intervention to assist in the management of this vulnerable population. Our institution has created a multidisciplinary transitional care program to address the needs of those discharged from the hospital with chronic complex conditions, including symptomatic pleural effusions. METHODS: This case series was performed in a transitional care clinic between May 8, 2017, and December 11, 2018. Eight unique patients with symptomatic pleural effusions were referred to our clinic posthospital discharge and treated with ultrasound-guided thoracentesis. A retrospective review was performed to assess procedure details, complications, and follow-up emergency department visits or hospital readmissions. Additionally, cost comparison data were obtained from the hospital financial system. RESULTS: Of the 8 unique patients, 15 thoracenteses were performed over the 19-month period in the transitional care clinic. The median age of the cohort was 56 years old (range: 39-92 years). All patients reported an immediate relief of symptoms (dyspnea and/ or pain) and no procedural complications. The total cost of performing an ultrasound-guided thoracentesis in the transitional care clinic was 61.8% that of performing the procedure in the hospital (US$537.61 vs US$869.65). CONCLUSION: All 8 patients experienced an immediate relief in pleural effusion-related symptoms following thoracentesis. Our experience helps reveal the safety, efficacy, and cost-efficiency of ultrasound-guided thoracentesis in providing symptom management for patients with pleural effusions in a transitional care clinic.

Is there any role for thoracoscopy in the diagnosis of benign pleural effusions.

Thoracoscopy in the endoscopy suite, has a high diagnostic yield of undiagnosed pleural effusions with minimal and mild complications. Whereas relatively minimal invasive techniques, such as thoracentesis, image-guided pleural biopsy or blind pleural biopsy, can yield sufficient cell or tissue material to establish the diagnosis of the underlying condition, more definite invasive diagnostic and therapeutic procedure, such as thoracoscopy, may be required for accurate sampling and diagnosis, and further provide real-time treatment options in same procedure. If thoracoscopy is considered the gold standard for the diagnosis is a fact in case. The current review aims to provide informations on thoracoscopy indications in benign pleural diseases according to up to date publications.

Risk Stratification in Patients with Complicated Parapneumonic Effusions and Empyema Using the RAPID Score.

PURPOSE: Complicated parapneumonic effusions and empyema are a leading cause of morbidity in the United States with over 1 million admissions annually and a mortality rate that remains high in spite of recent advances in diagnosis and treatment. The identification of high risk patients is crucial for improved management and the provision of cost-effective care. The RAPID score is a scoring system comprised of the following variables: renal function, age, purulence, infection source, and dietary factors and has been shown to predict outcomes in patients with pleural space infections. METHODS: In a single center retrospective study, we evaluated 98 patients with complicated parapneumonic effusions and empyema who had tube thoracostomy (with or without Intrapleural fibrinolytic therapy) and assessed treatment success rates, mortality, length of hospital stay, and direct hospitalization costs stratified by three RAPID score categories: low-risk (0-2), medium risk (3-4), and high-risk (5-7) groups. RESULTS: Treatment success rate was 71%, and the 90 day mortality rate was 12%. There was a positive-graded association between the low, medium and high RAPID score categories and mortality, (5.3%, 8.3% and 22.6%, respectively), length of hospital stay (10, 21, 19 days, respectively), and direct hospitalization costs ($19,909, $36,317 and $43,384, respectively). CONCLUSION: Our findings suggest that the RAPID score is a robust tool which could be used to identify patients with complicated parapneumonic effusions and empyema who may be at an increased risk of mortality, prolonged hospitalization, and who may incur a higher cost of treatment. Randomized controlled trials identifying the most effective initial treatment modality for medium- and high-risk patients are needed.

When students become patients: TB disease among medical undergraduates in Cape Town, South Africa.

BACKGROUND: Medical students acquire latent tuberculosis (TB) infection at a rate of 23 cases/100 person-years. The frequency and impact of occupational TB disease in this population are unknown. METHODS: A self-administered questionnaire was distributed via email and social media to current medical students and recently graduated doctors (2010 - 2015) at two medical schools in Cape Town. Individuals who had developed TB disease as undergraduate students were eligible to participate. Quantitative and qualitative data collected from the questionnaire and semi-structured interviews were analysed with descriptive statistics and a framework approach to identify emerging themes. RESULTS: Twelve individuals (10 female) reported a diagnosis of TB: pulmonary TB (n=6), pleural TB (n=3), TB lymphadenitis (n=2) and TB spine (n=1); 2/12 (17%) had drug-resistant disease (DR-TB). Mean diagnostic delay post consultation was 8.1 weeks, with only 42% of initial diagnoses being correct. Most consulted private healthcare providers (general practitioners (n=7); pulmonologists (n=4)), and nine underwent invasive procedures (bronchoscopy, pleural fluid aspiration and tissue biopsy). Substantial healthcare costs were incurred (mean ZAR25 000 for drug-sensitive TB, up to  ZAR104 000 for DR-TB). Students struggled to obtain treatment, incurred high transport costs and missed academic time. Students with DR-TB interrupted their studies and experienced severe side-effects (hepatotoxicity, depression and permanent ototoxicity). Most participants cited poor TB infection-control practices at their training hospitals as a major risk factor for occupational TB. CONCLUSIONS: Undergraduate medical students in Cape Town are at high risk of occupationally acquired TB, with an unmet need for comprehensive occupational health services and support.

Deep Needle Procedures: Improving Safety With Ultrasound Visualization.

Promoting patient safety and increasing health care quality have dominated the health care landscape during the last 15 years. Health care regulators and payers are now tying patient safety outcomes and best practices to hospital reimbursement. Many health care leaders are searching for new technologies that not only make health care for patients safer but also reduce overall health care costs. New advances in ultrasonography have made this technology available to health care providers at the patient's bedside. Point-of-care ultrasound assistance now aids providers with real-time diagnosis and with visualization for procedural guidance. This is especially true for common deep needle procedures such as central venous catheter insertion, thoracentesis, and paracentesis.There is now mounting evidence that clinician-performed point-of-care ultrasound improves patient safety, enhances health care quality, and reduces health care cost for deep needle procedures. Furthermore, the miniaturization, ease of use, and the evolving affordability of ultrasound have now made this technology widely available. The adoption of point-of-care ultrasonography has reached a tipping point and should be seriously considered the safety standard for all hospital-based deep needle procedures.

Examining Invasive Bedside Procedure Performance at an Academic Medical Center.

OBJECTIVES: Explore the performance patterns of invasive bedside procedures at an academic medical center, evaluate whether patient characteristics predict referral, and examine procedure outcomes. METHODS: This was a prospective, observational, and retrospective chart review of adults admitted to a general medicine service who had a paracentesis, thoracentesis, or lumbar puncture between February 22, 2013 and February 21, 2014. RESULTS: Of a total of 399 procedures, 335 (84%) were referred to a service other than the primary team for completion. Patient characteristics did not predict referral status. Complication rates were low overall and did not differ, either by referral status or location of procedure. Model-based results showed a 41% increase in the average length of time until procedure completion for those referred to the hospital procedure service or radiology (7.9 vs 5.8 hours; P < 0.05) or done in radiology instead of at the bedside (9.0 vs 5.8 hours; P < 0.001). The average procedure cost increased 38% ($1489.70 vs $1023.30; P < 0.001) for referred procedures and 56% ($1625.77 vs $1150.98; P < 0.001) for radiology-performed procedures. CONCLUSIONS: Although referral often is the easier option, our study shows its shortcomings, specifically pertaining to cost and time until completion. Procedure performance remains an important skill for residents and hospitalists to learn and use as a part of patient care.

Factors Associated with Inpatient Thoracentesis Procedure Quality at University Hospitals.

BACKGROUND: Physicians increasingly refer thoracentesis procedures to interventional radiology (IR) rather than performing them at the bedside. Factors associated with thoracentesis procedures at university hospitals were studied to determine clinical outcomes by provider specialty. METHODS: An administrative database review was performed of patients who underwent an inpatient thoracentesis procedure in hospitals participating in the University HealthSystem Consortium (UHC) Database from January 2010 through September 2013. The incidence of iatrogenic pneumothorax, mean total hospital costs, and mean length of stay (LOS) were compared by clinical specialty. RESULTS: There were 113,860 admissions with 132,472 thoracentesis procedures performed on 99,509 patients at 234 UHC hospitals. IR performed 43,783 (33%) thoracentesis procedures; medicine, 22,243 (17%); and pulmonary, 26,887 (20%). The incidence of iatrogenic pneumothorax was 2.8% for IR, 2.9% for medicine, and 3.1% for pulmonary. Medicine and pulmonary had equivalent risk of iatrogenic pneumothorax compared to IR after controlling for clinical covariates. Admissions with medicine and pulmonary procedures were associated with significantly lower costs compared to IR admissions (p < 0.001) after controlling for clinical covariates. Admissions with IR procedures had a mean LOS of 14.1 days; medicine, 13.2 days; and pulmonary, 15.9 days. Admissions with medicine and pulmonary procedures were associated with fewer hospital days when compared to IR in the controlled model (p < 0.001). CONCLUSION: Admissions with medicine and pulmonary bedside thoracentesis procedures are as safe and less costly than IR procedures. Shifting IR thoracentesis procedures to the bedside might be a potential way to reduce hospital costs while still ensuring high-quality patient care, provided that portable ultrasound is used.

Management of Malignant Pleural Effusion: A Cost-Utility Analysis.

BACKGROUND: Malignant pleural effusion (MPE) is associated with a significant impact on health-related quality of life. Palliative interventions abound, with varying costs and degrees of invasiveness. We examined the relative cost-utility of 5 therapeutic alternatives for MPE among adults. METHODS: Original studies investigating the management of MPE were extensively researched, and the most robust and current data particularly those from the TIME2 trial were chosen to estimate event probabilities. Medicare data were used for cost estimation. Utility estimates were adapted from 2 original studies and kept consistent with prior estimations. The decision tree model was based on clinical guidelines and authors' consensus opinion. Primary outcome of interest was the incremental cost-effectiveness ratio for each intervention over a less effective alternative over an analytical horizon of 6 months. Given the paucity of data on rapid pleurodesis protocol, a sensitivity analysis was conducted to address the uncertainty surrounding its efficacy in terms of achieving long-term pleurodesis. RESULTS: Except for repeated thoracentesis (RT; least effective), all interventions had similar effectiveness. Tunneled pleural catheter was the most cost-effective option with an incremental cost-effectiveness ratio of $45,747 per QALY gained over RT, assuming a willingness-to-pay threshold of $100,000/QALY. Multivariate sensitivity analysis showed that rapid pleurodesis protocol remained cost-ineffective even with an estimated probability of lasting pleurodesis up to 85%. CONCLUSIONS: Tunneled pleural catheter is the most cost-effective therapeutic alternative to RT. This, together with its relative convenience (requiring neither hospitalization nor thoracoscopic procedural skills), makes it an intervention of choice for MPE.

[Parapneumonic pleural effusions: Epidemiology, diagnosis, classification and management]. / Les épanchements pleuraux parapneumoniques: épidémiologie, diagnostic, classification, traitement.

Parapneumonic pleural effusions represent the main cause of pleural infections. Their incidence is constantly increasing. Although by definition they are considered to be a "parapneumonic" phenomenon, the microbial epidemiology of these effusions differs from pneumonia with a higher prevalence of anaerobic bacteria. The first thoracentesis is the most important diagnostic stage because it allows for a distinction between complicated and non-complicated parapneumonic effusions. Only complicated parapneumonic effusions need to be drained. Therapeutic evacuation modalities include repeated therapeutic thoracentesis, chest tube drainage or thoracic surgery. The choice of the first-line evacuation treatment is still controversial and there are few prospective controlled studies. The effectiveness of fibrinolytic agents is not established except when they are combined with DNase. Antibiotics are mandatory; they should be initiated as quickly as possible and should be active against anaerobic bacteria except for in the context of pneumococcal infections. There are few data on the use of chest physiotherapy, which remains widely used. Mortality is still high and is influenced by underlying comorbidities.