Prediction of Patient's Adherence to the Post-Intubation Tracheal Stenosis Follow-up Plan in Iran: Application of two Data Mining Techniques.

BACKGROUND: Timely diagnosis of post-intubation tracheal stenosis (PITS), which is one of the most serious complications of endotracheal intubation, may change its natural history. To prevent PITS, patients who are discharged from the intensive care unit (ICU) with more than 24 hours of intubation should be actively followed-up for three months after extubation. This study aimed to evaluate the abilities of artificial neural network (ANN) and decision tree (DT) methods in predicting the patients' adherence to the follow-up plan and revealing the knowledge behind PITS screening system development requirements. MATERIALS AND METHODS: In this cohort study, conducted in 14 ICUs during 12 months in ten cities of Iran, the data of 203 intubated ICU-discharged patients were collected. Ten influential factors were defined for adherences to the PITS follow-up (P<0.05). A feed-forward multilayer perceptron algorithm was applied using a training set (two-thirds of the entire data) to develop a model for predicting the patients' adherence to the follow-up plan three months after extubation. The same data were used to develop a C5.0 DT in MATLAB 2010a. The remaining one-third of data was used for model testing, based on the holdout method. RESULTS: The accuracy, sensitivity, and specificity of the developed ANN classifier were 83.30%, 72.70%, and 89.50%, respectively. The accuracy of the DT model with five nodes, 13 branches, and nine leaves (producing nine rules for active follow-up) was 75.36%. CONCLUSION: The developed classifier might aid care providers to identify possible cases of non-adherence to the follow-up and care plans. Overall, active follow-up of these patients may prevent the adverse consequences of PITS after ICU discharge.

Clinical Significance of Quantitative FDG PET/CT Parameters in Non-Small Cell Lung Cancer Patients.

BACKGROUND: An initial evaluation of non-small cell lung cancer (NSCLC) patients with 18F- fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) scan can modify treatment planning. We investigated the clinical significance of FDG PET/CT quantitative parameters (QPs) in NSCLC patients. MATERIALS AND METHODS: We included 125 NSCLC patients for initial staging FDG PET/CT scan. The primary tumor (T), regional lymph node metastases (N), and distant metastases (M) were evaluated on FDG PET/CT images. QPs, including standard uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were calculated separately for each T, N, and M lesion and also for the whole body. Statistical analysis through SPSS version 22 was used to evaluate the clinical significance of PET/CT QPs concerning primary tumor pathology characteristics, initial tumor stage, and patient's prognosis. RESULTS: We followed the patients for 19.28 (±11.42) months. Considering primary tumor pathology, there was a significant difference in FDG PET/CT QPs, including primary tumor SUVmax (p=0.00), metastases SUVmax (p=0.014), whole-body MTV (p=0.045), and whole-body TLG (p=0.002). There was also a significant difference in QPs, including primary tumor SUVmax (p=0.00) and regional lymph node metastases SUVmax (p=0.048) when accounting for tumor initial stage. There was a significant prognostic value for the whole-body TLG (p=0.01) and a cut-off point of 568 was reached to differentiate better versus worse survival outcome. CONCLUSION: We demonstrated a statistically significant difference in FDG PET/CT QPs when accounting for primary NSCLC pathology characteristics and initial stage, as well as patient's prognosis, and recommend incorporating QP values into clinical PET/CT reports.

Technical Details of Surgical Treatment of a Severely Displaced Sternal Fracture.

Sternal fracture is an uncommon injury, which is managed conservatively in most patients. In case of failure of non-surgical management or severely displaced fractures, open reduction and internal fixation should be considered. In this case report, we present the technical details of open reduction and internal fixation for a severely displaced sternal fracture in a bicyclist. The sternal fracture was successfully treated, and the patient benefited from the rapid control of symptoms, early mobilization, and good cosmetic outcome. CONCLUSION: Open surgical treatment of a sternal fracture, when indicated, can be performed safely, with rapid control of symptoms, low risk of non-union, and good cosmetic outcome.

Item Selection and Content Validity of the Risk Factors of Post-Intubation Tracheal Stenosis Observation Questionnaire for ICU-Admitted Patients.

BACKGROUND: Laryngotracheal stenosis as a late complication of prolonged endotracheal intubation is a life-threatening event. In order to determine the related risk factors for this complication, which may vary among different countries, designing a valid questionnaire is necessary. The aim of this study was to select the items and evaluate the face and content validities of a questionnaire developed for assessment of risk factors of post-intubation tracheal stenosis (PITS) in patients admitted in the intensive care unit. MATERIALS AND METHODS: A mixed method study design was used in four steps in 2015, i.e., 1) a literature review, 2) focus groups with five experts in the field, 3) consultations with intensive care unit (ICU) specialists and thoracic surgeons, and 4) evaluation of content and face validity with 15 experts in a scientific panel using two self-administered questionnaires. Content validity index (CVI) was computed for individual items as well as the overall scale. RESULTS: We extracted the items from different sources of information. An initial version of the 52-item questionnaire was developed and classified into four domains including patient characteristics, intubation features, equipment-drugs, and complications. The items with an excellent modified kappa were included in the questionnaire. Five questions received more criticism instead of support and were removed (Item-CVI<0.55, fair modified kappa). The ones with an Item-CVI > 0.60 and a good modified kappa were revised, merged, or retained. The new 43-item questionnaire found a scale-level CVI, averaging (Scale-CVI/Ave) of 0.91. CONCLUSION: The PITS risk factors questionnaire was developed and validated through item selection, expert opinions, and content validity index.

Obstructive Tracheal Pseudomembrane.

Obstructive tracheal pseudomembrane is a rare complication of endotracheal intubation, which could cause fatal airway obstruction following extubation. Hereby, we reported a patient who had only undergone a short course of intubation for a laparoscopic cholecystectomy and developed progressive respiratory distress after extubation.

Investigation of the Mechanical Properties of the Human Tracheal Cartilage.

BACKGROUND: The tracheal cartilage plays an important role in maintaining the mechanical stability of the trachea, as it keeps the trachea open and prevents its collapse under the negative pressures of the respiratory cycle. This study aimed to evaluate and compare the mechanical properties of cartilage specimens from the cranial and caudal regions of the human trachea and compare the results with respect to age and sex of the subjects. MATERIALS AND METHODS: After obtaining human trachea samples from brain-dead, organ-donating patients and storing them in appropriate conditions, the prepared cartilage samples from the cranial and caudal regions of the trachea were subjected to uniaxial tension and stress relaxation experiments to obtain the corresponding Young's modulus and relaxation percentage values, respectively. The results were compared in terms of the position (cranial or caudal) in the trachea, and age and sex of the patients. RESULTS: Based on the results, no statistically significant effect of the position in the trachea on the Young's modulus of the human tracheal cartilage samples was observed, despite the generally stiffer behavior of cartilage samples from the cranial region compared to those from the caudal region of the trachea. For both the cranial and caudal regions, no significant effect of sex on the stiffness of the tracheal cartilage was observed; further, the cartilage samples of the human trachea (from both cranial and caudal regions) of the old subjects were significantly stiffer than those of the young subjects. Based on the stress relaxation data, no significant effect of age, sex, or position on the relaxation percentage was observed. CONCLUSION: The tracheal cartilage samples of the old patients are significantly stiffer than those of the young patients. Sex and position in the trachea (cranial vs caudal) do not significantly influence the mechanical properties of the human tracheal cartilage samples. The results of this study can be useful in designing tracheal tissue-engineered scaffolds, which should be mechanically compatible with the native trachea.

Surgical Antibiotic Prophylaxis: A Descriptive Study among Thoracic Surgeons.

BACKGROUND: Surgical site infections (SSIs) are common complications following surgeries and increase mortality, morbidity and healthcare costs. The use of antimicrobial prophylaxis is an effective measure to prevent development of SSIs. This study aimed to evaluate the current use of prophylactic antibiotics in thoracic surgeries in Iran. MATERIALS AND METHODS: A descriptive study was conducted among thoracic surgeons in order to assess their knowledge, attitude and practice (KAP) about surgical antibiotic prophylaxis (SAP). A four-section multiple-choice questionnaire was designed and hand-delivered to registered thoracic surgeons. The surgeons' answers were considered correct when they were in accordance to the American Society of Health-System Pharmacist (ASHP) guidelines. RESULTS: Seventy thoracic surgeons were requested to participate in this study and their response rate was 71.4%. Thirty-five (70%) surgeons had good knowledge about appropriate SAP. However, less than half of the respondents were aware of appropriate SAP in case of Ig E-mediated reaction to penicillin and risk of Gram-negative infections. The surgeon's attitude score about the need for local and national guidelines for SAP was 78% and 90%, respectively. Accordance of the physician's practice with ASHP guidelines regarding timing of the first dosage of SAP was acceptable while correct administration of an intraoperative dose was 40% in agreement with the guideline. CONCLUSION: Although thoracic surgeons had a good attitude towards antibiotic prophylaxis guidelines, their knowledge and practice should be improved for proper administration of SAP.

Lymphangiomatosis: The Cause of Refractory Pleural Effusion in a Patient with Lupus Erythematosus.

Mediastinal cavernous lymphangioma is a rare mediastinal lesion and its association with lupus erythematosus has not yet been reported in the literature. We present a 25 year-old female with lupus erythematosus who had bilateral massive refractory and recurrent pleural effusion as well as ascites for a long period of time. During surgery, a huge multicystic lesion with a thick wall, covering the entire parietal and visceral pleura was found, which was subsequently proven to be a cystic cavernous lymphangioma.

Gorham's Disease With Chest Wall Involvement: A Case Report and a Review of the Literature.

INTRODUCTION: Gorham's disease is a rare disorder characterized by osteolysis and abnormal vascular growth within bones. Diagnosis of Gorham's disease is often delayed and for accurate and early diagnosis high clinical suspicion is crucial. No specific treatment is available. Management options include surgery, radiation therapy and medical therapy. We aimed to present the first case of Gorham's disease with chest wall involvement in Iran. By review of the literature we discussed important issues of this rare disease including clinical findings, diagnosis and treatment options. CASE PRESENTATION: We present a 48-year-old man with a history of dyspnea following a blunt chest trauma who was admitted to our clinic several times due to reaccumulation of pleural fluid and chylothorax. Gorham's disease was finally established according to clinical manifestations and radiological findings including massive osteolysis in his left ribs and also histological examination. DISCUSSION: According to review of the literature and considering all treatment modalities the patients was successfully treated with a combination of radiotherapy, pamidronate and thalidomide. We suggest that this disease should be considered among differential diagnoses of patients with chest pain, pleural effusion and/or chylothorax with an unknown reason and more importantly history of chest trauma. In suspected cases, it is essential to examine biopsy specimens of the bone adjacent to the inflammated tissues in order to confirm diagnosis.

The cost of lung transplantation in Iran.

BACKGROUND: Lung transplantation is one of the most complicated medical procedures. The aim of the present study is to report the average cost of lung transplantation in Iran.
MATERIAL/METHODS: We reviewed the hospital data of all lung transplantations performed in Masih Daneshvari Hospital, Tehran, Iran, from 2000 to 2008 and extracted information on the costs for hospitalization for the transplantation surgery. We excluded the patients who died shortly after the transplantation surgery.We then categorized the costs into seven distinct groups: accommodations, personnel, medication, paraclinics, supplies, procedures and other costs. Data was primarily extracted based on Iranian national currency (Rials) and then converted to US dollar (10,000 Rials = 1$). The mean of the costs are reported for each category.
RESULTS: The mean total cost of lung transplantation was 13,801.6+/-7,752.3 USD (range: 6,104.9 to 26,888.7). This cost was related to the specified categories as followed: Expenditure tools = 35.55%, medications = 34.46%, personnel cost = 10.14%, accommodations = 8.14%, procedures = 5.66%, paraclinics = 5.49%, other costs = 0.56%.
CONCLUSIONS: The cost of lung transplantation is high. This could be due to the complexity of the procedure, the large number of specialists involved, long duration of hospital stay and high rate of complications that might occur following the surgery. The results of the present study also showed that the cost of lung transplantation in Iran is far below the reported costs from other countries.