Lung lobectomy surgical approach and resource utilization differ by anatomic lobe in a statewide discharge registry.

Background: Anatomic lobe-specific differences with respect to pulmonary lobectomy have been suggested in the thoracic surgery literature but hard data has been lacking in larger population studies in part due to coding systems that do not distinguish pulmonary lobectomy by anatomic lobe. International Classification of Diseases, Tenth Revision (ICD-10) procedure codes, adopted in the United States in 2015, may provide novel methodologic accessibility for pulmonary lobectomy studies as they classify lobectomy operations by specific anatomic lobe. We queried the Texas Inpatient Public Use Data File (TPUDF) ICD-10 codes for both open and endoscopic approach lobectomy with a specific view to differences based on anatomic lobes. Methods: Between fourth fiscal quarter (Q4) 2015 and Q4 2017, all pulmonary lobectomy operations performed in Texas state-licensed hospitals were identified by querying the TPUDF for ICD-10 procedure codes for pulmonary lobectomy as classified by anatomic lobe. Surgical approach, additional procedures and diagnosis codes, length of hospital stay (LOS), and discharge status were recorded with aggregate values undergoing statistical analysis. Results: Right and left upper versus lower lobe resections were more prevalent however minimally invasive surgery was less commonly performed for upper than right lower lobectomy. LOS, irrespective of surgical approach, was longer for upper versus lower lobe resection as was need for transfer to additional inpatient facilities. LOS was longer and need for additional surgical or procedural interventions days after the primary procedure of lobectomy was greater for right versus left upper lobe resection, suggesting some differential properties of the right versus left pleural space. Conclusions: The marked clinical differences between anatomic lobes in the setting of pulmonary lobectomy observed in this study have the potential to translate to differences in expected hospital and health system costs and surgeon time-expenditure and experience premium that currently have no mechanism for their accounting. These findings highlight the value of ICD-10 coding for analysis of pulmonary lobectomy in administrative databases and suggest a possible path to more informed patient counseling and equitable hospital and surgeon reimbursement based on payment adjustment by anatomic lobe in pulmonary lobectomy operations.

Diagnostic and Management Strategies in Patients with Late Recurrent Angina after Coronary Artery Bypass Grafting.

PURPOSE OF REVIEW: This review will outline the current evidence on the anatomical, functional, and physiological tools that may be applied in the evaluation of patients with late recurrent angina after coronary artery bypass grafting (CABG). Furthermore, we discuss management strategies and propose an algorithm to guide decision-making for this complex patient population. RECENT FINDINGS: Patients with prior CABG often present with late recurrent angina as a result of bypass graft failure and progression of native coronary artery disease (CAD). These patients are generally older, have a higher prevalence of comorbidities, and more complex atherosclerotic lesion morphology compared to CABG-naïve patients. In addition, guideline recommendations are based on studies in which post-CABG patients have been largely excluded. Several invasive and non-invasive diagnostic tools are currently available to assess graft patency, the hemodynamic significance of native CAD progression, left ventricular function, and myocardial viability. Such tools, in particular the latest generation coronary computed tomography angiography, are part of a systematic diagnostic work-up to guide optimal repeat revascularization strategy in patients presenting with late recurrent angina after CABG.

Usefulness of Transcatheter Aortic Valve Implantation for Treatment of Pure Native Aortic Valve Regurgitation.

Patients with pure native aortic valve regurgitation (NAVR) and increased surgical risk are often denied surgery. This retrospective study aimed to evaluate the "off-label" use of transcatheter heart valves (THV) for the treatment of NAVR. A total of 254 high surgical risk patients with NAVR (age 74 ± 12 years, Society of Thoracic Surgeons risk score 6.6 ± 6.2%) underwent transcatheter aortic valve implantation (TAVI) with early generation (43%) or newer generation (57%) devices at 46 different sites. Device success was significantly higher in patients treated with newer as compared with early generation THV (82% vs 47%, p <0.001). The difference was driven by lower rates of device malpositioning (9% vs 33%) and aortic regurgitation (AR) ≥ moderate (4% vs 31%) and translated into higher clinical efficacy at 30 days in patients treated with newer as compared with early generation THV (72% vs 56%, p = 0.041). Both THV under- and oversizing were associated with an increased risk of THV malpositioning. In conclusion, TAVI is a feasible treatment strategy in selected high-risk patients with NAVR but is associated with a considerable risk of THV malpositioning and residual AR. Although newer-generation THV are associated with better outcomes, novel devices for the treatment of NAVR are warranted.

Patients with mental illness as victims of homicide: a national consecutive case series.

BACKGROUND: The media attention received by homicides committed by patients with mental illness is thought to increase stigma. However, people with mental illness can also be victims of violence. We aimed to assess how often victims of homicide are current mental health patients and their relationship to the perpetrators. METHODS: In a national consecutive case-series study, we obtained data for victims and perpetrators of all confirmed homicides between Jan 1, 2003, and Dec 31, 2005, in England and Wales. We requested information about contact with mental health services in the 12 months before the homicide for all victims and perpetrators. For victims and perpetrators who had contact with mental health services in the 12 months before homicide, we sent questionnaires to the clinician responsible for the patient's care. FINDINGS: 1496 victims of confirmed homicide died between Jan 1, 2003, and Dec 31, 2005, in England and Wales. Patients with mental illness were more likely to die by homicide than were people in the general population (incidence rate ratio 2·6, 95% CI 1·9-3·4). 90 homicide victims (6%) had contact with mental health services in the 12 months before their death. 213 patients with mental illness were convicted of homicide in the same 3 year period. 29 of 90 patient victims were killed by another patient with mental illness. In 23 of these 29 cases, the victim and perpetrator were known to each other, and in 21 of these cases, the victims and perpetrators were undergoing treatment at the same National Health Service Trust. In these 29 cases in which patient victims were killed by another patient with mental illness, alcohol and drug misuse (19 victims [66%], 27 perpetrators [93%]) and previous violence (7 victims [24%], 7 perpetrators [24%]) were common in both victims and, particularly, perpetrators. In seven of the 29 cases in which the victim was killed by another patient with mental illness, both victim and perpetrator were diagnosed with schizophrenia. INTERPRETATION: The high risk of patients with mental illness being victims of homicide is an important antistigma message, although this risk partly comes from other patients with mental illness; overall, the risk of patients committing homicide is greater than the risk of being a victim of homicide. Identification and safeguarding of patients at risk of violence should be prominent in clinical risk assessment. FUNDING: Healthcare Quality Improvement Partnership.

Evaluation of a low-cost, portable imaging system for early detection of oral cancer.

BACKGROUND: There is an important global need to improve early detection of oral cancer. Recent reports suggest that optical imaging technologies can aid in the identification of neoplastic lesions in the oral cavity; however, there is little data evaluating the use of optical imaging modalities in resource limited settings where oral cancer impacts patients disproportionately. In this article, we evaluate a simple, low-cost optical imaging system that is designed for early detection of oral cancer in resource limited settings. We report results of a clinical study conducted at Tata Memorial Hospital (TMH) in Mumbai, India using this system as a tool to improve detection of oral cancer and its precursors. METHODS: Reflectance images with white light illumination and fluorescence images with 455 nm excitation were obtained from 261 sites in the oral cavity from 76 patients and 90 sites in the oral cavity from 33 normal volunteers. Quantitative image features were used to develop classification algorithms to identify neoplastic tissue, using clinical diagnosis of expert observers as the gold standard. RESULTS: Using the ratio of red to green autofluorescence, the algorithm identified tissues judged clinically to be cancer or clinically suspicious for neoplasia with a sensitivity of 90% and a specificity of 87%. CONCLUSIONS: Results suggest that the performance of this simple, objective low-cost system has potential to improve oral screening efforts, especially in low-resource settings.

Imaging performance of a miniature integrated microendoscope.

An integrated miniature multi-modal microscope (4M device) for microendoscopy was built and tested. Imaging performance is evaluated and imaging results are presented for both fluorescence and reflectance samples. Images of biological samples show successful imaging of both thin layers of fixed cells prepared on a slide as well as thick samples of excised fixed porcine epithelial tissue, thus demonstrating the potential for in vivo use.

Fluorescent nanocrystals for use in early cervical cancer detection.

BACKGROUND: Quantum dots (qdots) are a promising alternative to organic fluorophores for biological imaging. Advantages of quantum dots over organic fluorophores include broad excitation coupled with narrow, tunable emission, high resistance to chemical and metabolic degradation, a higher photobleaching threshold and finally the ability to be modified with a targeting ligand. These many properties allow quantum dots to be used in conjunction with optical detection methods for imaging. METHODS: We are investigating the use of quantum dots to detect precancerous biomarkers. We have directly targeted epidermal growth factor receptors with quantum dots conjugated to anti-EGFR antibodies. RESULTS: Compared to appropriate controls, we do see specific labeling of EGF receptors. CONCLUSIONS: Quantum dots provide a promising alternative to conventional organic dyes for biological imaging. Combined with optical imaging technologies, quantum dots can help visualize changes in cervical cancer at the molecular level. This ability may alert health care providers to the need for intervention before a cancer can metastasize.