Outpatient management of pneumothorax after fine-needle aspiration: economic advantages for the hospital and patient.

PURPOSE: To evaluate the efficacy and cost savings of outpatient management of post-fine-needle aspiration (FNA) pneumothoraces with small-caliber catheters. MATERIALS AND METHODS: The authors retrospectively reviewed the medical and hospital billing records from 74 patients with enlarging or symptomatic post-FNA pneumothoraces treated with a small-caliber catheter. Forty patients (54%) were treated on an outpatient basis, 17 patients (23%) were treated on an inpatient basis, and 17 patients (23%) were monitored overnight in the emergency department. Only one patient initially treated on an outpatient basis had to return for inpatient observation and suction because of a persistent pneumothorax. RESULTS: The catheters remained in place overnight in 46 patients (33 outpatients, 12 emergency department patients, and one inpatient). The number of days the catheters were left in place was prolonged (range, 2-13 days) in seven outpatients, five emergency department patients, and 16 inpatients. The mean cost per patient for lung biopsy and pneumothorax management was as follows: outpatients, $1,689; emergency department patients, $2,403; and inpatients, $3,950. Elevated inpatient expense was related to the number of chest radiographs obtained, pharmacy charges, and room charges. Cost elevation for emergency department patients was related to pharmacy charges and the cost of overnight observation. CONCLUSION: Outpatient management of simple pneumothoraces with placement of small-caliber catheters attached to one-way chest drain valves proved to be safe, efficient, and economical.

Sigmoid sinus thrombosis associated with internal jugular venous occlusion: direct thrombolytic treatment.

PURPOSE: To report our experience with transfemoral direct venous thrombolysis and angioplasty to treat central venous and dural sinus occlusion. The cases presented are rare examples of internal jugular occlusion associated with sigmoid sinus thrombosis. METHODS AND RESULTS: Two middle-aged, symptomatic female patients were diagnosed with sigmoid sinus and internal jugular vein thrombosis. Venography was performed from a contralateral transfemoral approach, followed immediately by urokinase infusion directly to the occlusion using an intermittent "burst-bolus" technique. Successful thrombolysis of the sigmoid sinus and internal jugular vein was documented in both patients. In one case, a venous stenosis was treated with balloon angioplasty. Clinical signs and symptoms resolved in both patients. CONCLUSIONS: Occluded dural sinuses and central veins can be treated with direct administration of thrombolytic agents. When an underlying stenosis is identified, balloon dilation should be used to reduce the likelihood of recurrence.

Microbial etiology and clinical characteristics of distributive shock.

Although septic shock may be the most common cause of distributive shock, to our knowledge, no studies have defined the likelihood and type of infection among patients with distributive shock. We performed a retrospective study of 100 consecutive patients who were admitted to a city-county hospital with hemodynamic evidence of distributive shock. Forty-nine of 100 patients with distributive shock had microbiological documentation of infection. Six patients had clinical evidence of infection without microbiological documentation. Forty-five patients had no microbiological or clinical evidence of infection. Among patients with microbiologically documented infections, the incidence of infection due to aerobic gram-positive cocci equaled the incidence of infection due to aerobic gram-negative bacilli. Clinical parameters, such as the criteria for the systemic inflammatory response syndrome, were not useful in distinguishing the group with infections from the group without infections. In conclusion, many patients with distributive shock do not have evidence of infection.