Anteroposterior chest radiograph vs. chest CT scan in early detection of pneumothorax in trauma patients.

Pneumothorax is a common complication following blunt chest wall trauma. In these patients, because of the restrictions regarding immobilization of the cervical spine, Anteroposterior (AP) chest radiograph is usually the most feasible initial study which is not as sensitive as the erect chest X-ray or CT chest for detection of a pneumothorax. We will present 3 case reports which serve for better understanding of the entity of occult pneumothorax. The first case is an example of a true occult pneumothorax where an initial AP chest X-ray revealed no evidence of pneumothorax and a CT chest immediately performed revealed evidence of pneumothorax. The second case represents an example of a missed rather than a truly occult pneumothorax where the initial chest radiograph revealed clues suggesting the presence of pneumothorax which were missed by the reading radiologist. The third case emphasizes the fact that "occult pneumothorax is predictable". The presence of subcutaneous emphesema and pulmonary contusion should call for further imaging with CT chest to rule out pneumothorax. Thoracic CT scan is therefore the "gold standard" for early detection of a pneumothorax in trauma patients. This report aims to sensitize readers to the entity of occult pneumothorax and create awareness among intensivists and ER physicians regarding the proper diagnosis and management.

The impact of bariatric surgery on the Veterans Administration healthcare system: a cost analysis.

BACKGROUND: The economic burden of caring for veterans with clinically severe obesity and its comorbidities is straining the Veterans Administration (VA) healthcare system. The authors determined the cost of Roux-en-Y Gastric Bypass (RYGBP) in the VA's single-payor healthcare system. METHODS: The records of all 25 patients who underwent RYGBP from May 1999 to October 2001 were reviewed. All obesity-related health-care costs including hospitalizations as well as outpatient visits, medications and home health devices were calculated for 12 months before and after the RYGBP. RESULTS: Age was 52+/-2 yr and preoperative BMI was 52+/-2 kg/m(2); ASA score was III (21 patients) and II (4 patients). Mean follow-up was 18 months. Total cost of care for these patients preoperatively was $10,778+/-2,460/patient (outpatient visits=$5,476+/-682, hospital admissions=$12,221+/-6,062, and home health devices=$1,383+/-349). Postoperative length of stay was 8+/-0.5 days. Cost of the gastric bypass was $8,976+/-497/pt (OR fixed cost=$1,900/patient + ICU and ward=$7,076+/-497/patient). For the first postoperative year, 6 patients had 12 admissions, but routine outpatient visits were significantly reduced from 55+/-6 to 18+/-2 postoperatively (P<0.001). The cost of all care excluding peri-operative charges for 1 year after gastric bypass was $2,840+/-622/patient (P=0.005 vs preop). CONCLUSIONS: Operative treatment of clinically severe obesity reduces obesity-related expenditures and utilization of healthcare resources. The cost of undertaking RYGBP at the VA is offset by reduction of health-care costs within the first year after surgery. These data support allocation of resources to support existing bariatric surgery programs throughout the VA system.

Male breast carcinoma: correlation of ER, PR, Ki-67, Her2-Neu, and p53 with treatment and survival, a study of 65 cases.

Male breast cancer is rare, and experience of it in any single institution is limited. Our current understanding regarding its biology, natural history, and treatment strategies has been extrapolated from its female counterpart. The aim of this study is to evaluate the expression patterns of estrogen receptor (ER), progesterone receptor (PR), MiB1 (Ki67), Her-2/neu (c-erbB2), and p53 and to correlate them with the prognosis, presentation, staging, management, and survival/outcome in male breast carcinoma identified through the Veterans Administration nationwide cancer registry. Sixty-five cases of male breast cancer were reviewed for classification. Tumor blocks were requested from each institution for immunohistochemical staining and evaluation of ER, PR, p53, Her2-neu, and MiB1. Seventeen age- and disease-matched male veteran patients with breast gynecomastia were used as controls. Traditional prognostic data were collected for comparison with female breast cancers (i.e., age, lymph node status, clinical staging, tumor size, histological grade, and disease-free and overall survival). Male breast carcinoma had worse disease-free survival than controls (P =.03). The clinical stage regardless of tumor size or lymph node metastasis was the single most significant prognostic factor (P <.0001). ER-positive patients appeared to have a better survival than did ER-negative patients (P =.03, univariate; P not significant in multivariate) and did not benefit from treatment with tamoxifen (P =.0027, univariate; P =.42, multivariate). MiB1 and PR expressions did not correlate with treatment or survival, and p53 was associated with shorter disease free survival (P =.07, univariate; P =.047, multivariate). Stage for stage, Her2-neu was associated with shorter disease-free survival (P <.0001) and correlated with positive lymph nodes (P =.08). Surgery alone versus surgery with adjuvant treatments (chemotherapy, radiotherapy, tamoxifen, or combination) did not show any survival difference. Adjuvant therapy seemed to be associated with worse outcome. In the Veterans Administration hospital setting, the clinical stage and the expressions of p53 and Her2-neu in male breast carcinoma may be prognostically useful markers in guiding future treatment in prospective studies, whereas ER, PR, and MiB1 expressions are of limited value.