Management of Early-Stage Resected Non-Small Cell Lung Cancer: Consensus Statement of the Lung cancer Consortium.

BACKGROUND: Management of early-stage non-small cell lung cancer (ES-NSCLC) has evolved over the last few years especially in terms of work-up and the use of systemic therapy. This consensus statement was developed to present updated guidelines for the management of this disease. METHODS: Multidisciplinary team (MDT) of lung cancer experts convened to discuss a set of pertinent questions with importance relevance to the management of ES-NSCLC. ES-NSCLC includes stages I, II and resected stage III. The experts included consultants in chest imaging, thoracic surgery, radiation oncology, and medical oncology. Questions were discussed in virtual meetings and then a written manuscript with supporting evidence was drafted, reviewed, and approved by the team members. RESULTS: The Consensus Statement included 9 questions addressing work-up and management of ES-NSCLC. Background information and literature review were presented for each question followed by specific recommendations to address the questions by oncology providers. The Statement was endorsed by various oncology societies in the Gulf region. CONCLUSION: The Consensus Statement serves as a guide for thoracic MDT members in the management of ES-NSCLC. Adaptation of these to the local setting is dictated usually by available resources and expertise, however, all efforts should be excreted to provide the optimal care to all patients whenever possible.

Multi-disciplinary approach for the management of non-metastatic non-small cell lung cancer in the Middle East and Africa: Expert panel recommendations.

The Middle East and Africa (MEA) region, a large geographical area, lies at the confluence of Asian, Caucasian and African races and comprises of a population with several distinct ethnicities. The course of management of non-small cell lung cancer (NSCLC) differs as per patients' performance status as well as stage of disease, requiring personalized therapy decisions. Although management of NSCLC has received a significant impetus in the form of molecularly targeted therapies and immune therapies in last few years, surgery remains gold standard for patients with early-stage disease. In case of unresectable disease, radiotherapy and chemotherapy are the primary management modalities. With newer therapies being approved for treatment of early stage disease, use of multi-disciplinary team (MDT) for comprehensive management of NSCLC is of prime importance. A group of experts with interest in thoracic oncology, deliberated and arrived at a consensus statement for the community oncologists treating patients with NSCLC in the MEA region. The deliberation was based on the review of the published evidence including literature and global and local guidelines, subject expertise of the participating panellists and experience in real-life management of patients with NSCLC. We present the proposed regional adaptations of international guidelines and recommends the MDT approach for management of NSCLC in MEA.

Gallstone Dislodgement in the Airway during ERCP: A Case Report and Review of the Literature.

Endoscopic retrograde cholangiopancreatography (ERCP) is a diagnostic and therapeutic procedure with many studied complications. We are presenting a rare complication of ERCP in choledocholithiasis: gallstone dislodging into the airway upon retrieval. The patient is a 37-year-old female admitted with obstructive jaundice. She was evaluated, and her management plan included a referral for an ERCP to extract the impacted common bile duct stones. Upon retrieval of the gallstone, it fell out the basket and lodged into the airway which was confirmed on bronchoscopy and successfully retrieved. This report describes successful management of a rare but potentially dangerous complication of ERCP to remove impacted CBD stones. The possible complications of delayed removal or inability to remove gallstones from the airway have yet to be studied and reported but are likely to include recurrent chest infections, bronchiectasis, and empyema of the lung.

Automated Fall Detection Technology in Inpatient Geriatric Psychiatry: Nurses' Perceptions and Lessons Learned.

ABSTRACTHospitalized older adults are at high risk of falling. The HELPER system is a ceiling-mounted fall detection system that sends an alert to a smartphone when a fall is detected. This article describes the performance of the HELPER system, which was pilot tested in a geriatric mental health hospital. The system's accuracy in detecting falls was measured against the hospital records documenting falls. Following the pilot test, nurses were interviewed regarding their perceptions of this technology. In this study, the HELPER system missed one documented fall but detected four falls that were not documented. Although sensitivity (.80) of the system was high, numerous false alarms brought down positive predictive value (.01). Interviews with nurses provided valuable insights based on the operation of the technology in a real environment; these and other lessons learned will be particularly valuable to engineers developing this and other health and social care technologies.

Removal of cardiothoracic war-related shrapnel using video-assisted thoracoscopic surgery.

This is the first report in the literature to describe removing war-related cardiothoracic shrapnel using video-assisted thoracoscopic surgery (VATS). War blast caused penetrating thoracic and extremity injuries in 30-year-old man. He was referred to our hospital after stabilization. Magnetic resonance imaging was required to evaluate brachial plexus injury. Large, penetrating shrapnel fragment in the right posterior chest wall, retained shrapnel in apex of the right lung, and another fragment in the pericardium were removed using VATS in staged approach. Postoperative period was uneventful. VATS is useful in managing complex, war-related cardiothoracic injuries.

18F-FDG PET/CT assessment of histopathologically confirmed mediastinal lymph nodes in non-small cell lung cancer using a penalised likelihood reconstruction.

PURPOSE: To investigate whether using a Bayesian penalised likelihood reconstruction (BPL) improves signal-to-background (SBR), signal-to-noise (SNR) and SUVmax when evaluating mediastinal nodal disease in non-small cell lung cancer (NSCLC) compared to ordered subset expectation maximum (OSEM) reconstruction. MATERIALS AND METHODS: 18F-FDG PET/CT scans for NSCLC staging in 47 patients (112 nodal stations with histopathological confirmation) were reconstructed using BPL and compared to OSEM. Node and multiple background SUV parameters were analysed semi-quantitatively and visually. RESULTS: Comparing BPL to OSEM, there were significant increases in SUVmax (mean 3.2-4.0, p<0.0001), SBR (mean 2.2-2.6, p<0.0001) and SNR (mean 27.7-40.9, p<0.0001). Mean background SNR on OSEM was 10.4 (range 7.6-14.0), increasing to 12.4 (range 8.2-16.7, p<0.0001). Changes in background SUVs were minimal (largest mean difference 0.17 for liver SUVmean, p<0.001). There was no significant difference between either algorithm on receiver operating characteristic analysis (p=0.26), although on visual analysis, there was an increase in sensitivity and small decrease in specificity and accuracy on BPL. CONCLUSION: BPL increases SBR, SNR and SUVmax of mediastinal nodes in NSCLC compared to OSEM, but did not improve the accuracy for determining nodal involvement. KEY POINTS: • Penalised likelihood PET reconstruction was applied for assessing mediastinal nodes in NSCLC. • The new reconstruction generated significant increases in signal-to-background, signal-to-noise and SUVmax. • This led to an improvement in visual sensitivity using the new algorithm. • Higher SUV max thresholds may be appropriate for semi-quantitative analyses with penalised likelihood.

Novel penalised likelihood reconstruction of PET in the assessment of histologically verified small pulmonary nodules.

OBJECTIVES: Investigate the effect of a novel Bayesian penalised likelihood (BPL) reconstruction algorithm on analysis of pulmonary nodules examined with 18F-FDG PET/CT, and to determine its effect on small, sub-10-mm nodules. METHODS: 18F-FDG PET/CTs performed for nodule evaluation in 104 patients (121 nodules) were retrospectively reconstructed using the new algorithm, and compared to time-of-flight ordered subset expectation maximisation (OSEM) reconstruction. Nodule and background parameters were analysed semi-quantitatively and visually. RESULTS: BPL compared to OSEM resulted in statistically significant increases in nodule SUVmax (mean 5.3 to 8.1, p < 0.00001), signal-to-background (mean 3.6 to 5.3, p < 0.00001) and signal-to-noise (mean 24 to 41, p < 0.00001). Mean percentage increase in SUVmax (%ΔSUVmax) was significantly higher in nodules ≤10 mm (n = 31, mean 73%) compared to >10 mm (n = 90, mean 42 %) (p = 0.025). Increase in signal-to-noise was higher in nodules ≤10 mm (224%, mean 12 to 27) compared to >10 mm (165%, mean 28 to 46). When applying optimum SUVmax thresholds for detecting malignancy, the sensitivity and accuracy increased using BPL, with the greatest improvements in nodules ≤10 mm. CONCLUSION: BPL results in a significant increase in signal-to-background and signal-to-noise compared to OSEM. When semi-quantitative analyses to diagnose malignancy are applied, higher SUVmax thresholds may be warranted owing to the SUVmax increase compared to OSEM. KEY POINTS: • Novel Bayesian penalised likelihood PET reconstruction was applied for lung nodule evaluation. • This was compared to current standard of care OSEM reconstruction. • The novel reconstruction generated significant increases in lung nodule signal-to-background and signal-to-noise. • These increases were highest in small, sub-10-mm pulmonary nodules. • Higher SUV max thresholds may be warranted when using semi-quantitative analyses to diagnose malignancy.

What is the extent of the advantage of video-assisted thoracoscopic surgical resection over thoracotomy in terms of delivery of adjuvant chemotherapy following non-small-cell lung cancer resection?

OBJECTIVES: Video-assisted thoracoscopic surgery (VATS) lobectomy for early stage non-small cell lung cancer (NSCLC) is a safe and effective alternative to open lobectomy. Adjuvant chemotherapy is part of the treatment recommended for patients with performance status (PS) 0-1 following resection of NSCLC of stages T1-3 N1-2 M0 and T2-3 N0 M0. If VATS reduces morbidity, does it help delivery of postoperative chemotherapy? We studied our data to compare the delivery and toxicity of chemotherapy in patients following VATS or open lung resections. METHODS: We performed a retrospective study of all patients who had resection of primary NSCLC in a single surgical centre between October 2008 and August 2013. Surgical and chemotherapy databases were reviewed to extract data on patient characteristics, operative details, pathological stage, chemotherapy delivery and toxicity. RESULTS: Three hundred and twenty-three resections were undertaken for NSCLC; 142 (44%) underwent VATS resection and 181 (56%) open thoracotomy; 16 (11.3%) and 28 (15.5%) of each group received adjuvant chemotherapy, respectively. Patient demographics and tumour stage were as follows: median age (range) was 65.5 (44-77) vs 67.5 (49-76); male: 43.8 vs 50% (P = 1.0); Stage I/II 75 vs 76.9%; Stage III 12.5 vs 30.8%; pre-chemotherapy PS 0 75 vs 78.2% for VATS and thoracotomy groups, respectively. All patients received platinum/vinorelbine therapy. Chemotherapy was initiated significantly earlier in the VATS group (mean 55.7 ± 3.1 vs 68.2 ± 4.3 days, P = 0.046); 68.8% of patients in the VATS group completed four cycles of chemotherapy compared with 60.1% in the open group (P = 0.75). There was a non-significant trend towards reduction in Grade 3/4 haematological toxicity in the VATS group compared with the open group (12.5 vs 39.3%, P = 0.09). CONCLUSIONS: Adjuvant chemotherapy was started significantly earlier in patients following VATS lung resections for NSCLC compared with thoracotomy. There was also a trend towards improved tolerance with more complete courses and reduced haematological toxicity.

Cost-effectiveness of the convergent procedure and catheter ablation for non-paroxysmal atrial fibrillation.

OBJECTIVE: Patients with persistent or longstanding atrial fibrillation have modest success achieving sinus rhythm with catheter ablation or rhythm control medications. Their high risk of stroke, bleed, and heart failure leads to significant morbidity and health care costs. The convergent procedure has been shown to be successful in this population, with 80% of patients in sinus rhythm after 1 year. This study evaluated the cost-effectiveness of the convergent procedure, catheter ablation, and medical management for non-paroxysmal AF patients. METHODS: A Markov micro-simulation model was used to estimate costs and effectiveness from a payer perspective. Parameter estimates were from the literature. Three patient cohorts were simulated, representing lower, medium, and higher risks of stroke, bleed, heart failure, and hospitalization. Effects were estimated by quality-adjusted life-years (QALYs). Single-variable sensitivity analysis was performed. RESULTS: After 5 years, convergent procedure patients averaged 1.10 procedures, with 75% of survivors in sinus rhythm; catheter ablation patients had 1.65 procedures, with 49% in sinus rhythm. Compared to medical management, catheter ablation and the convergent procedure were cost-effective for the lower risk (ICER <$35,000) and medium risk (ICER <$15,000) cohorts. The procedures dominated medical management for the higher risk cohort (lower cost and higher QALYs). The convergent procedure dominated catheter ablation for all risk cohorts. RESULTS were subject to simplifying assumptions and limited by uncertain factors such as long-term maintenance of sinus rhythm after successful procedure and incremental AF-associated event rates for AF patients relative to patients in sinus rhythm. In the absence of clinical trial data, convergent procedure efficacy was estimated with observational evidence. Limitations were addressed with sensitivity analyses and a moderate 5 year time horizon. CONCLUSION: The convergent procedure results in superior maintenance of post-ablation sinus rhythm with fewer repeat ablation procedures compared to catheter ablation, leading to lower cost and higher QALYs after 5 years.

Cost effectiveness of radiofrequency microremodeling for stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Stress urinary incontinence (SUI) is a common and growing problem among adult women and affects individuals and society through decreased quality of life (QoL), decreased work productivity, and increased health care costs. A new, nonsurgical treatment option has become available for women who have failed conservative therapy, but its cost effectiveness has not been evaluated. This study examined the cost effectiveness of transurethral radiofrequency microremodeling of the female bladder neck and proximal urethra compared with synthetic transobturator tape (TOT), retropubic transvaginal tape (TVT) sling, and Burch colposuspension surgeries for treating SUI. METHODS: A Markov model was used to compare the cost effectiveness of five strategies for treating SUI for patients who had previously failed conservative therapy. The strategies were designed to compare the value of starting with a less invasive treatment. The cost-effectiveness analysis was conducted from the health care system perspective. Efficacy and adverse event rates were obtained from the literature; reimbursement costs were based on Medicare fee schedule. The model cycle was 3 months, with a 3-year time horizon. Single-variable sensitivity analyses were conducted to assess stability of base-case results. RESULTS: Two of the five strategies employed the use of transurethral radiofrequency microremodeling and achieved 17-30 % lower mean costs relative to their comparative sling or Burch strategies. CONCLUSIONS: Superior safety and cost effectiveness are recognized when patients are offered a sequential approach to SUI management that employs transurethral radiofrequency microremodeling before invasive surgical procedures. This sequential approach is consistent with treatment strategies for other conditions and offers a solution for women with SUI who want to avoid the inherent risks and costs of invasive continence surgery.

Is thymectomy in non-thymomatous myasthenia gravis of any benefit?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was if thymectomy in non-thymomatous myasthenia gravis was of any benefit? Overall, 137 papers were found using the reported search, of which 16 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. The outcome variables were similar in all of the papers, including complete stable remission (CSR), pharmacological remission, age at presentation, gender, duration of symptoms, preoperative classification (Oosterhius, Osserman or myasthenia gravis Foundation of America (MGFA)), thymic pathology, preoperative medications (steroids, immunosuppressants), mortality and morbidity. We conclude that evidence-based reviews have shown that relative rates of thymectomy patients compared with non-thymectomy patients attaining outcome indicate that the former group of patients is more likely to achieve medication-free remission, become asymptomatic and clinically improve (54%, P < 0.01), particularly patients with severe and generalized symptoms (P = 0.007). Patients with generalized myasthenia gravis showed 11% stronger association with favourable outcomes after thymectomy. Some studies show early remission rates (RRs), as early as 6 months post-thymectomy, of 44%. Overall, the reported remission rate for non-thymomatous myasthenia gravis is between 38 and 72% up to 10 years of follow-up. Among these patients, those with thymic hyperplasia show the best complete stable remission rates (42%, P < 0.04) in the majority of studies. Age showed variability across the studies and the cut-off was also different among them. Overall age < 45 years showed a higher probability of achieving complete stable remission during follow-up (81% benefit rate (BR), P < 0.02). Pharmacological improvement is reported between 6 and 42%. However, the certainty of these benefits has not been established due to factors such as the confounding differences between myasthenia gravis patients receiving and not receiving thymectomy, the non-randomized nature of class II studies and the lack of Class I evidence to support its use. There is currently a randomized trial ongoing looking at thymectomy by sternotomy vs controls and the results are eagerly awaited.

Tracheo-oesophageal compression due to massive spontaneous retropharyngeal haematoma.

Spontaneous retropharyngeal haematoma and dissecting intramural haematoma of the oesophagus are two distinct, but rare, phenomena. We describe the first case of complete tracheo-oesophageal obstruction due to spontaneous retropharyngeal haematoma presenting with chest pain and dysphagia. Rapid imaging allowed life-saving transfer to the regional specialist centre, with immediate surgical intervention. The importance, aetiology and clinical features of both diagnoses are discussed.

Cost of neuromodulation therapies for overactive bladder: percutaneous tibial nerve stimulation versus sacral nerve stimulation.

PURPOSE: Conservative therapy and antimuscarinic agents are first line therapies for overactive bladder. Patients refractory to treatment are candidates for neuromodulation therapy. We estimated the costs and cost-effectiveness of percutaneous tibial nerve stimulation and sacral nerve stimulation. MATERIALS AND METHODS: A Markov model was constructed to simulate the total costs and effectiveness of percutaneous tibial and sacral nerve stimulation during 2 years. Cost data used average Medicare national physician payments, and ambulatory payment classification and diagnosis related group payments for hospital based care and office visits. Clinical effectiveness, and the rates of patient adherence to treatment and adverse events were estimated by a review of the literature. RESULTS: The costs of initial therapy were $1,773 for 12 weekly percutaneous tibial nerve stimulation treatments and $1,857 for test sacral nerve stimulation. For ongoing therapy the cost of the sacral nerve stimulation surgical implant was $22,970. Cumulative discounted 2-year costs were $3,850 for percutaneous tibial nerve stimulation and $14,160 for sacral nerve stimulation, including those who discontinued therapy. Of the patients 48% and 49%, respectively, remained on therapy. The incremental cost-effectiveness ratio was $573,000 per additional patient on sacral nerve stimulation. When considering only patients who completed initial stimulation successfully, the costs were $4,867 and $24,342 for percutaneous tibial and sacral nerve stimulation with 71% and 90%, respectively, remaining on therapy for an incremental cost-effectiveness ratio of $99,872. CONCLUSIONS: Percutaneous tibial nerve stimulation and sacral nerve stimulation are safe, effective neuromodulation therapies for overactive bladder. In this economic model percutaneous tibial nerve stimulation had substantially lower cost. An additional 1% of patients would remain on therapy at 2 years if sacral nerve stimulation were used rather than percutaneous tibial nerve stimulation but the average cost per additional patient would be more than $500,000.

How successful is lung-preserving radical surgery in the mesothelioma and radical surgery-trial environment? A case-controlled analysis.

OBJECTIVE: To determine whether there is a survival benefit from open-lung-preserving surgery (radical decortication) for malignant mesothelioma, when compared with the non-radical approach in the mesothelioma and radical surgery (MARS)-trial era. METHODS: We compared outcomes between 13 patients with malignant mesothelioma, who underwent radical decortication (group RD, n = 13) with 13 case-matched patients, who had palliative surgery (group non-radical decortication (NRD), n = 13) over a period of 2 years from June 2006 onwards. Patients were matched for age, sex, histology, computed tomography (CT) stage, haematological indices, body mass index (BMI) and adjuvant chemotherapy. We compared perioperative and postoperative courses and long-term survival. RESULTS: Histology was 25% biphasic and 75% epithelioid in both the groups. There was no significant difference in the proportions receiving adjuvant chemotherapy (54%, p = 1.00), but more patients in the RD group received adjuvant radiotherapy (46% vs 15%, p = 0.20). Median survival was higher for all cell types in the RD group (16.9 months vs 6.8 months, p = 0.001). CONCLUSION: Radical open-lung-sparing surgery may confer a survival advantage to patients with malignant mesothelioma, who are fit to undergo radical decortication followed by chemotherapy and radiotherapy. Trials of radical surgery versus no surgery should include lung-sparing operations.

Predictors of risk tolerance among oral surgery patients.

PURPOSE: This study attempts to provide insight on how the treatment preference for a mandible fracture and treatment received and its consequences are related to the patient's risk tolerance, as measured by the Standard Gamble (SG). PATIENTS AND METHODS: Data from a prospective cohort study of 203 subjects receiving treatment at the former King/Drew Medical Center in Los Angeles, CA, for either a mandible fracture (n = 98) or third molar removal (n = 105) were examined. Subjects were interviewed at 4 time points: on admission to the medical center and at 3 monthly follow-up visits. Risk tolerance for hypothetical treatment scenarios is measured by use of the SG, a health-value utility measure assessing the tradeoff between good outcomes and serious complications associated with treatment. Separate regression analyses with subsets of predictors (sociodemographic, psychosocial health, and clinical characteristics) were conducted and then synthesized by use of the significant predictors in separate analyses. RESULTS: For fracture subjects, there was a noticeable rise in the SG reports from admission to the 1-month follow-up. Their greater risk tolerance was associated with being older, receiving surgery, having a lower post-traumatic stress disorder score, and having a swollen jaw or face. For third molar subjects, SG did not change substantively over the course of the study. Predictors of greater risk tolerance for third molar subjects included the jaw or face being swollen and having to use less pain medication. CONCLUSIONS: Findings from this study show a preference for less invasive treatment, with the majority of both groups preferring wiring, and support the theory that treatment choices differ between subjects with different health states. Factors associated with risk tolerance include the patient's age, treatment received, psychosocial health state, experience with previous treatment, and value for oral health quality of life.

Surgical assessment of malignant pleural mesothelioma: have we reached a critical stage?

OBJECTIVE: The International Mesothelioma Interest Group (IMIG) classification is the most widely used staging system but is based on post-resectional parameters. We aimed to test the association between clinical and pathological staging and to identify possible discrepancies. METHODS: We identified 164 consecutive patients (144 males and 20 females, with mean age 58 years) who underwent radical surgery (114 extrapleural pneumonectomy; 50 radical pleurectomy/decortication) for malignant pleural mesothelioma (MPM). The patients were clinically staged with CT + or - MRI (CT, computed tomography; MRI, magnetic resonance imaging). RESULTS: Clinical T (cT) stage proved to be the same as pathological T (pT) stage in 44%; understaged in 46% and overstaged in 10%. Clinical N (cN) stage proved to be the same as pathological N (pN) stage in 56%; understaged in 31% and overstaged in 13%. Disease-free interval (DFI) was associated with cT stage (median DFI 29 months, SE 13, 95% CI 3-54 months for cT1; median 5, SE 3, 95% CI 3-6 months for cT4, p=0.02) but not clinical N stage (median DFI 12 months, SE 1, 95% CI 9-15 months for cN0; median DFI 11 months, SE 0.3, 95% CI 10-12 months for cN2, p=0.5) and was associated with both pT (median DFI 31 months, SE 17, 95% CI 0-64 months for pT1; median DFI 8 months, SE1, 95% CI 6-11 months for pT4, p=0.03) and pN stage (median DFI 14 months, SE 3, 95% CI 9-20 months for pN0; median DFI 10 months, SE 1, 95% CI 8-13 months for pN2, p=0.02). Overall survival was associated with cT stage (median survival 25 months, SE 3, 95% CI 20-30 months for cT1; median survival 11 months, SE 3, 95% CI 10-11 months for cT4, p=0.01) but not cN stage (median survival 15 months, SE 2, 95% CI 11-19 months for cN0; median survival 15 months, SE 2, 95% CI 12-19 months for cN2, p=0.49) and pN stage (median survival 22 months, SE 3, 95% CI 19-27 months for pN0; median survival 14 months, SE 1, 95% CI 12-17 months for pN2, p=0.01) but not pT stage (median survival 27 months, SE 4, 95% CI 19-35 months for pT1; median survival 12 months, SE 2, 95% CI 9-15 months for pT4, p=0.06). Pathological IMIG stage was associated with DFI and overall survival; however, preoperative IMIG stage was less useful. CONCLUSIONS: There are deficiencies in the current staging system for MPM and discrepancies between clinical and pathological systems. Future improvements are needed in clinical descriptors of nodal status and pathological descriptors of T stage. Subsequent IMIG stage grouping also needs revision.

Surgical management of primary empyema of the pleural cavity: outcome of 81 patients.

Postpneumonic empyema is the most common form of empyema thoracis and is still recognised as a major cause of morbidity and prolonged hospital stay. We reviewed 106 patients retrospectively who underwent surgical management of pleural empyema over a period of three years from August 2005. We identified 81 patients (76%) (58 males, mean age 52 years) with primary empyema and 25 patients (24%) with secondary empyema. The first group of patients with primary empyema was analysed. Twenty-nine patients (36%) had stage II empyema and 52 patients (64%) had stage III. The majority of stage II empyema patients underwent thoracoscopic debridement (28 patients) and one patient had open thoracotomy and debridement. Stage III patients underwent thoracoscopic decortication (32 patients) of those six patients (19%) were converted to open decortication, open decortication (19 patients) and fenestration (one patient). Mortality rate was 0% for all procedures. Median length of hospital stay was six days for thoracoscopic debridement, five days for thoracoscopic decortication and eight days for open decortication. Patients treated with video-assisted thoracoscopic surgery (VATS) debridement or decortication spent less time in hospital and the conversion rate to open procedure for stage III empyema was only 19%, which encourages us to consider VATS debridement/decortication as a first choice treatment.

Predictors of treatment preference for mandibular fracture.

BACKGROUND: Patient treatment preferences do not necessarily remain stable over time. OBJECTIVE: This study focuses on predictors of patient treatment choice and on the extent to which patients are willing to take risks by choosing surgical versus nonsurgical treatment for mandibular fracture. METHODS: Surveys of African-American and Hispanic adults receiving treatment at King/Drew Medical Center for either a mandibular fracture (n = 98) or third-molar removal (n = 105) were used to investigate patterns of patient preference over the course of a 4-month study period using generalized estimating equations controlling for age, gender, income, and fracture versus third-molar patient. The study examined the effects of symptom rating and a"standard gamble" measure reflecting a patient's willingness to accept scarring or nerve damage. This analysis is based on 169 patients who participated in four waves of data collection. RESULTS: The most salient predictor of patient treatment was the standard gamble measure at 1-month follow-up. Subjects with higher risk tolerance were more likely to select surgery versus jaw wiring. A higher likelihood of choosing surgery was associated with higher income and greater symptom severity. Fracture patients were more likely to select surgery compared with third-molar patients. CONCLUSIONS: The significance of symptom severity 1-month post-surgery raises an important issue regarding the healing process. Moreover, the significance of standard gamble as a predictor of treatment choice for mandibular fracture should encourage other researchers to use this measure of willingness to accept risk when studying acute conditions such as jaw fracture.