An unusual cause of subacute airway obstruction in a hemodialysis patient with brachio-cephalic arteriovenous fistula: A rare presentation of central venous occlusion.

A young lady with an arteriovenous (AV) fistula on hemodialysis was referred for surgical management following a failed endovascular approach to relieve central venous occlusion. She had an obstructed left brachiocephalic vein with a history of numerous central vein catheter placements. Alternative routes for new arteriovenous fistula creation had been exhausted due to previous contralateral upper limb fistula rupture and ligation. To the best of our knowledge, no similar cases of airway obstruction in central venous occlusion occurring in hemodialysis patients with AV fistula have been reported. The importance of identifying the possible emergency red flags in hemodialysis patients with central venous occlusion is important to prevent unwanted consequences.

Impacto de la reforma del copago farmacéutico sobre la utilización de medicamentos antidiabéticos, antitrombóticos y para la obstrucción crónica del flujo aéreo / Impact of the pharmaceutical copayment reform on the use of antidiabetics, antithrombostics and drugs for chronic airflow obstructions. Spain

Fundamentos: En 2012 cambió la legislación española que regulaba el copago farmacéutico de la prestación farmacéutica del Sistema Nacional de Salud (SNS). El objetivo fue conocer si este cambio afecta al consumo de los medicamentos para enfermedades crónicas, tales como antidiabéticos, antitrombóticos y fármacos contra padecimientos obstructivos de las vías respiratorias. Método: Estudio observacional longitudinal retrospectivo. Se utilizaron modelos de regresión lineal segmentada general para series de tiempo interrumpido. Las variables analizadas fueron el número de dosis diarias definidas (DDDs) y el importe de la facturación de las dispensaciones financiadas y no financiadas por el SNS desde septiembre de 2010 hasta agosto de 2015 (T=60). Resultados: La tasa de variación estimada de las DDDs fue negativa pero decreciente para los 3 subgrupos terapéuticos a los 6, 12, 24 y 38 meses de la intervención: -0,1% para antidiabéticos a los 6 meses y 0,3% a los 38 meses; -3,7% para antitrombóticos a los 6 meses y -4,6% a los 38 meses; -2,7% a los 6 meses para anti-asma y EPOC y -1,3% a los 38 meses. Se estimó una reducción mantenida y significativa del gasto únicamente en el subgrupo para asma y EPOC: -5,2% a los 6 meses, -7,0% a los 12 meses y a los 24 meses y -6,2% a los 38 meses. Conclusiones: La reforma del copago farmacéutico de 2012 ocasionó una reducción inmediata y significativa en el número de dosis diarias definidas de los tres grupos terapéuticos estudiados. Este efecto nivel no fue permanente ya que se acompañó de un cambio en la tendencia de crecimiento en los meses post-intervención que, en parte, compensó el efecto sobre el nivel (AU)

Background: In 2012 it changed the Spanish legislation regulating the pharmaceutical copayment by the National Health System (NHS). The objective was to know if the Spanish pharmaceutical copayment reform in 2012 has affected drugs consumptions for chronic diseases such as antidiabetics, antithrombotics and agents against obstructive conditions of the respiratory tract. Methods: Retrospective longitudinal observational study, using general segmented linear regression models for interrupted time series. The variables analyzed were the number of defined daily doses (DDDs) and the amount corresponding to public funding and not public funding from the NHS since September 2010 to August 2015 (T=60). Results: The estimated variation rate of DDDs is negative but decreasing for the three therapeutic subgroups at 6, 12, 24 and 38 months after the intervention: The estimated variation rate of DDDs is negative but decreasing for the most part of the three therapeutic subgroups at 6, 12, 24 and 38 months after the intervention: -0.1% for antidiabetics after 6 months and 0.3% after 38 months; -3.7% for antithrombotics after 6 months and -4.6% after 38 months; -2.7% for asthma and COPD drugs after 6 months and -1.3% after 38 months. A sustained and significant reduction in expenditure was estimated only in the subgroup of asthma and COPD drugs: -5.2% after 6 months, -7.0% after 12 months and after 24 months, and -6.2% after 38 months. Conclusions: The pharmaceutical copayment reform of 2012 led to an immediate and significant reduction in the number of DDDs of all three therapeutic subgroups selected in this study. This level effect is not permanent, as it is accompanied by a change in the growth trend in the post-intervention months, which has partly offset the effect on the level (AU)

Delivery of heliox with a semi-closed circuit during spontaneous breathing: a comparative economic theoretical study.

BACKGROUND: Heliox is a mixture of oxygen and helium which reduces airway resistance in patients with airway obstruction. In clinical practice, patients breathing spontaneously receive heliox via an open circuit. Recently, a semi-closed circuit for heliox administration has been proposed which minimizes consumption of heliox and therefore cost of the heliox therapy; although, the semi-closed circuit is associated with additional costs. The aim of the study is to conduct an economical analysis comparing total cost of heliox therapy using an open versus a semi-closed circuit in spontaneously breathing patients with airway obstruction. METHODS: Four different systems for heliox administration were analyzed: an open circuit and three alternatives of a semi-closed circuit involving a custom made semi-closed circuit and two standard anesthesia machines. Total costs of heliox therapy were calculated for all the systems. For calculation of gas consumption, the clinical procedures limiting continuous heliox therapy including the aerosol therapy, personal hygiene and nutrition were taken into account. A sensitivity analysis was conducted for main input variables that may influence the results of the study. RESULTS: Price of gases consumed by a semi-closed system represents less than 20 % of price of gases when a standard open circuit is used. This represents a saving of approximately 540 EUR per patient. The initial cost of the custom-made semi-closed circuit recuperates after treatment of 18 patients. The corresponding number of patients is 32 when a low-cost anesthesia machine is initially acquired and rises to 69 when a highly advanced anesthesia machine is considered. CONCLUSIONS: Heliox therapy in spontaneously breathing patients using a semi-closed circuit becomes more cost-effective compared to the open circuit, currently used in clinical practice, when applied in a sufficient number of cases. The impact of finding a cheaper way of heliox administration on the clinical practice needs to be ascertained.

Hereditary angioedema treatment options: the availability of new therapies.

Hereditary angioedema (HAE) is a potentially life-threatening autosomal dominant disease characterized by recurrent episodes of oedema, commonly occurring in the skin, abdomen, and upper respiratory tract. After many years during which limited treatment options were available, a range of newer therapies with proven efficacy have been approved in Europe by the European Commission for the treatment of HAE attacks. However, due to differing legislation and financial restrictions, these treatment options are not available in all countries. Home therapy and self-administration of treatment are recommended in order to minimize the burden of disease upon the patient, with the ideal treatment option being effective, well-tolerated, and easy to prepare and administer. Recently, the Hereditary Angioedema International Working Group (HAWK) consensus recommended early, on-demand treatment for HAE. This article reviews the current treatment options available, and considers the need for treatment guidelines to recommend the appropriate therapy.

The utility of interventional pulmonary procedures in liberating patients with malignancy-associated central airway obstruction from mechanical ventilation.

PURPOSE: Utilization of intensive care services by patients with malignancy has risen during the past several decades. Newer cancer therapies have improved overall survival and outcomes. Patients with respiratory failure from central airway obstruction related to tumor growth were previously viewed as inappropriate candidates for ventilator support. However, an increasing number of reports suggest that interventional pulmonary (IP) procedures may benefit such patients. METHODS: We reviewed the literature for case reports or case series from the past 20 years regarding the use of IP procedures for the treatment of respiratory failure from malignancy-associated central airway obstruction. RESULTS: As a whole, IP procedures were greater than 60 % successful in liberating patients from mechanical ventilation. Moreover, IP procedures served to palliate respiratory symptoms, prolong overall survival, allow for additional cancer treatments, and reduce hospitalization costs. Nevertheless, it remains unclear who may benefit the most from these procedures. CONCLUSIONS: Although data are limited, IP procedures are generally safe and should be considered for appropriate patients with respiratory failure from malignancy-associated central airway obstruction as a potential means of liberation from mechanical ventilation.

Economic advantages to a distraction decision tree model for management of neonatal upper airway obstruction.

BACKGROUND: Neonatal upper airway obstruction demands urgent attention. Tracheostomy can prove to be lifesaving but has morbidities. Recently, the authors found reduced morbidity/mortality when using a distraction decision tree model compared with conventional "case-by-case" management. In this current study, the authors assess the long-term costs of (1) a decision tree model versus conventional treatment and (2) tracheostomy versus distraction osteogenesis. METHODS: An inpatient cost-matrix analysis study on neonates with upper airway obstruction and micrognathia was performed (n=149). In Part I, conventionally treated neonates managed on a case-by-case basis received home monitoring or a tracheostomy. Decision tree model-managed newborns had specialist consultations and diagnostic testing to determine whether home monitoring, tracheostomy, or distraction osteogenesis would be implemented. In Part II, tracheostomy treatment was compared directly to distraction osteogenesis. RESULTS: In Part I (conventional versus decision tree model), taking into account the costs of the distraction, tracheostomy, hospital stay, diagnostic studies, physician fees, and emergency department visits, the total per patient treatment cost was 1.5 greater in the conventional treatment group ($332,673) compared with the decision tree model ($225,998) (p<0.05). In Part II (tracheostomy versus distraction osteogenesis), the total per-patient treatment cost in the tracheostomy group was two times greater than in the distraction group ($382,246 versus $193,128) (p<0.05). CONCLUSIONS: In treating newborns with micrognathia and upper airway obstruction, a decision tree model with mandibular distraction decreases long-term health care costs compared with conventional treatment. Furthermore, when comparing distraction to tracheostomy, similar decreases in long-term health care costs occurred.

Nd-YAG laser vs bronchoscopic electrocautery for palliation of symptomatic airway obstruction: a cost-effectiveness study.

STUDY OBJECTIVE: To evaluate the cost effectiveness of the Nd-YAG laser and bronchoscopic electrocautery for palliation in patients with symptomatic tumor obstruction. DESIGN: A retrospective study. SETTING: Bronchoscopy unit of a university hospital. PATIENTS AND INTERVENTION: Thirty-one consecutive patients with inoperable non-small cell lung cancer and symptomatic intraluminal tumor underwent bronchoscopic treatment. Dyspnea relief was the primary goal of treatment. Fourteen patients were treated with the Nd-YAG laser and 17 patients with electrocautery. MEASUREMENTS AND RESULTS: Improvement of symptoms was achieved in 70% of patients treated by either Nd-YAG laser or electrocautery. Mean +/- SD survival was 8.0 +/- 2.5 months after Nd-YAG laser treatment and 11.5 +/- 3.5 months after electrocautery. The number of treatment sessions per patient was comparable: Nd-YAG laser, 1.1; electrocautery, 1.2. Duration of hospital stay was longer in patients treated with the Nd-YAG laser (8.4 vs 6.7 days). Average treatment costs, including admission charges, were $5,321 for the Nd-YAG laser and $4,290 for electrocautery. Higher costs in the group treated with the Nd-YAG laser were caused by a longer hospital stay before bronchoscopic treatment. Costs of equipment (electrocautery $6,701 and Nd-YAG laser $208,333), write-offs, maintenance, and repair were not included in this calculation. CONCLUSION: Bronchoscopic electrocautery is equally effective but is a less expensive and, in our hospital, a more accessible modality than the Nd-YAG laser for symptomatic palliation of patients with intraluminal airway obstruction.

A cost-effective and rational surgical approach to patients with snoring, upper airway resistance syndrome, or obstructive sleep apnea syndrome.

The past decade has seen several innovations in the surgical techniques available for treatment of patients with sleep-disordered breathing. Outpatient techniques such as laser-assisted uvulopalatoplasty (LAUP) and more aggressive procedures designed to address hypopharyngeal and base of tongue obstruction (genioglossus advancement and hyoid myotomy) have been developed and proven successful. We describe the efficacy of LAUP for snoring (72.7%), upper airway resistance syndrome (81.8%), and mild (mean [+/-SD] respiratory disturbance index [RDI] = 12 +/- 8.1) obstructive sleep apnea (41.7%) in 56 patients who underwent 132 LAUP procedures in a 26-month period. Thirty-two patients with more significant obstructive sleep apnea (mean RDI = 41.8 +/- 23.1) underwent multilevel pharyngeal surgery consisting of genioglossus advancement and hyoid myotomy combined with uvulopalatopharyngoplasty. The surgical success rate in this group of patients was 85.7% when commonly accepted criteria were applied. We recommend a stratified surgical approach to patients with sleep-disordered breathing. Progressively worse airway obstruction marked by multilevel pharyngeal collapse and more severe sleep-disordered breathing is treated with incrementally more aggressive surgery addressing multiple areas of the upper airway.

Income level and asthma prevalence and care patterns.

Manitoba has a universally accessible health-care system that records physician contacts and hospitalizations in such a way that they can be ascribed to individuals. We examined the prevalence of physician-diagnosed asthma, bronchitis, and airways obstruction (total respiratory morbidity [TRM]) in Winnipeg in 1988 and 1992, using place of residence to divide people into quintiles according to average family income. Physician office visits, hospitalizations, and consultation referrals were each examined. Three age groups: 0 to 14 yr, 15 to 34 yr, and > or = 35 yr were studied. The prevalence of TRM was greater in low- than in high-income quintiles. Asthma prevalence was unrelated to income in the younger age groups; in the older group asthma was more common in low-income groups, but was less strongly related to income than was TRM. Asthma prevalence increased over the years studied, but the increase was not related to income level. There was some evidence of income-related diagnostic bias in that low-income patients were more likely to be labeled with a related diagnosis in addition to asthma than were high-income patients. Low-income patients had more physician contacts than did high-income patients. In terms of physician office visits, care continuity did not differ among income quintiles. Low-income quintiles had more hospitalizations than did high-income quintiles, and differences were larger than could be accounted for by diagnostic bias; asthma was probably more severe in low-income quintiles. High-income quintiles had more consultation referrals than did low-income quintiles.