Hybrid model: a promising type of public procurement in the healthcare sector of the European Union

The management of health supplies in public hospitals has been a major concern of national and European institutions over time, often being a field of reforms and regulatory interventions. Health procurement systems constitute complex decision-making and supply chain management mechanisms of public hospitals, involving suppliers, health providers, administrators and political bodies. Due to this complexity, the first important decision to be taken when designing a procurement system, concerns the degree of centralization, namely to what extent the decision-making power on the healthcare procurement (what, how and when) will be transferred either to a central public authority established for this purpose, or to the competent local authorities. In this perspective, we attempt to analyse the types of public procurement in the healthcare sector of the European Union, in terms of degree of centralization. Employing a narrative approach that summarizes recent interdisciplinary literature, this perspective finds that the healthcare procurement systems of the EU Member States, based on the degree of centralization, are categorized into three types of organizational structures: Centralized, Decentralized and Hybrid procurement. Each structure offers advantages and disadvantages for health systems. According to this perspective, a combination of centralized and decentralized purchases of medical supplies represents a promising hybrid model of healthcare procurement organization by bringing the benefits of two methods together.

Unexpected Lung Collapse Following Chest Tube Insertion for Pneumothorax Drainage in an Intubated Patient Due to Dislocation of the Endotracheal Tube

A 67-year-old male patient was admitted to the intensive care unit following an uncomplicated heart operation. The initial postoperative chest X-ray revealed a total pneumothorax on the left side. Despite drainage of the left pleural space, a subsequent chest X-ray unexpectedly showed opacification of the left hemithorax. Partial withdrawal of the endotracheal tube resulted in complete expansion of the left lung. It is important to always consider the possibility of endotracheal tube dislocation in all intubated patients.

Which Is the Best Way to Treat Massive Hemoptysis? A Systematic Review and Meta-Analysis of Observational Studies

INTRODUCTION

Hemoptysis is one of the most common symptoms of respiratory system diseases. Common causes include bronchiectasis, tumors, tuberculosis, aspergilloma, and cystic fibrosis. The severity of hemoptysis varies from mild to moderate to massive hemoptysis and can easily lead to hemodynamic instability and death from suffocation or shock. Nevertheless, the most threatening hemoptysis that is presented to the emergency department and requires hospitalization is the massive one. In these cases, today, the most common way to manage hemoptysis is bronchial artery embolization (BAE).

METHODS

A systematic literature search was conducted in PubMed and Scopus from January 2017 (with the aim of selecting the newest possible reports in the literature) until May 2023 for studies reporting massive hemoptysis. All studies that included technical and clinical success rates of hemoptysis management, as well as rebleeding and mortality rates, were included. A proportional meta-analysis was conducted using a random-effects model.

RESULTS

Of the 30 studies included in this systematic review, 26 used bronchial artery embolization as a means of treating hemoptysis, with very high levels of both technical and clinical success (greater than 73.7% and 84.2%, respectively). However, in cases where it was not possible to use bronchial artery embolization, alternative methods were used, such as dual-vessel intervention (80% technical success rate and 66.7% clinical success rate), customized endobronchial silicone blockers (92.3% technical success rate and 92.3% clinical success rate), antifibrinolytic agents (50% clinical success rate), and percutaneous transthoracic embolization (93.1% technical success rate and 88.9% clinical success rate), which all had high success rates apart from antifibrinolytic agents. Of the 2467 patients included in these studies, 341 experienced rebleeding during the follow-up period, while 354 other complications occurred, including chest discomfort, fever, dysphagia, and paresis. A total of 89 patients died after an episode of massive hemoptysis or during the follow-up period. The results of the meta-analysis showed a pooled technical success of bronchial artery embolization equal to 97.22% and a pooled clinical success equal to 92.46%. The pooled recurrence was calculated to be 21.46%, while the mortality was 3.5%. These results confirm the ability of bronchial artery embolization in the treatment of massive hemoptysis but also emphasize the high rate of recurrence following the intervention, as well as the risk of death.

CONCLUSION

In conclusion, massive hemoptysis can be treated with great clinical and technical success using bronchial artery embolization, reducing mortality. Mortality has now been reduced to a small percentage of cases.

Volumetric Tissue Imaging of Surgical Tissue Specimens Using Micro-Computed Tomography: An Emerging Digital Pathology Modality for Nondestructive, Slide-Free Microscopy-Clinical Applications of Digital Pathology in 3 Dimensions

OBJECTIVES

Micro-computed tomography (micro-CT) is a novel, nondestructive, slide-free digital imaging modality that enables the acquisition of high-resolution, volumetric images of intact surgical tissue specimens. The aim of this systematic mapping review is to provide a comprehensive overview of the available literature on clinical applications of micro-CT tissue imaging and to assess its relevance and readiness for pathology practice.

METHODS

A computerized literature search was performed in the PubMed, Scopus, Web of Science, and CENTRAL databases. To gain insight into regulatory and financial considerations for performing and examining micro-CT imaging procedures in a clinical setting, additional searches were performed in medical device databases.

RESULTS

Our search identified 141 scientific articles published between 2000 and 2021 that described clinical applications of micro-CT tissue imaging. The number of relevant publications is progressively increasing, with the specialties of pulmonology, cardiology, otolaryngology, and oncology being most commonly concerned. The included studies were mostly performed in pathology departments. Current micro-CT devices have already been cleared for clinical use, and a Current Procedural Terminology (CPT) code exists for reimbursement of micro-CT imaging procedures.

CONCLUSIONS

Micro-CT tissue imaging enables accurate volumetric measurements and evaluations of entire surgical specimens at microscopic resolution across a wide range of clinical applications.

Prognostic value of combined preoperative phase angle and handgrip strength in cardiac surgery

OBJECTIVES

Phase angle (PA) constitutes a bioelectrical impedance measurement, indicating cell membrane health and integrity, hydration, and nutritional status. Handgrip strength (HS) has been also associated with body composition, nutritional status, inflammation, and functional ability in several chronic diseases. Although their prognostic significance as independent biomarkers has been already investigated regarding the outcomes of a cardiac surgery, our study is the first one to assess the combined predictive value of preoperative PA and HS.

DESIGN AND METHODS

HS and PA measurements were performed preoperativelyin 195 patients undergoing cardiac surgery. The association ofthe combination of HS and PAwith all-cause mortality rates was the primary study outcome, while its association with the intensive care unit (ICU) length of stay (LOS) was the secondary one.

RESULTS

PA was positively correlated with HS (r = 0.446, p < 0.005) and negatively with EuroSCORE II (r = - 0.306 p < 0.005). The combination of PA < 5.15 and HS < 25.5 was associated with higher one-year all-cause mortality (OR = 9.28; 95% CI 2.50-34.45; p = 0.001) compared to patients with PA > 5.15 and HS > 25.5, respectively. Patients with combined lower values of PA and HS (PA < 5.15 and HS < 30.7) were at higher risk of prolonged ICU LOS (OR = 4.02; 95% CI 1.53-10.56; p = 0.005) compared to those with higher PA-HS (PA > 5.15-HS > 30.7). The combination of PA-HS was also significantly linked with EuroSCORE II.

CONCLUSION

The combination of low preoperative PA and HS values was significantly associated with higher risk of all-cause mortality at 12 months and prolonged ICU LOS; thereby it might serve as a clinically useful prognostic biomarker after cardiac surgery procedures.

Coexistence of squamous cell tracheal papilloma and carcinoma treated with chemotherapy and radiotherapy: a case report

BACKGROUND

Papillomatosis presents, most frequently, as multiple lesions of the respiratory tract, which are usually considered benign. Malignant degeneration into squamous cell carcinoma is quite common, although curative approaches vary a lot in modern literature.

CASE REPORT

We report a case of a 66-year-old male patient with the coexistence of multiple squamous cell papilloma and carcinoma in the upper trachea with severe airway obstruction that was diagnosed through bronchoscopy and treated by performing an urgent tracheostomy, followed by concurrent chemotherapy and radiotherapy. There was no evidence of recurrence after a 12-month follow-up period.

CONCLUSION

This study underlines the diagnostic and therapeutic value of bronchoscopy as well as multimodality palliative treatment in such cases. To the best of our knowledge, this is the first study to describe an immediate treatment protocol with tracheostomy and concurrent chemotherapy/radiotherapy in a patient with squamous cell tracheal papilloma and carcinoma.

Steroids In caRdiac Surgery (SIRS) trial: acute kidney injury substudy protocol of an international randomised controlled trial

INTRODUCTION

Steroids In caRdiac Surgery trial (SIRS) is a large international randomised controlled trial of methylprednisolone or placebo in patients undergoing cardiac surgery with the use of a cardiopulmonary bypass pump. At the time of surgery, compared with placebo, methylprednisolone divided into two intravenous doses of 250 mg each may reduce the risk of postoperative acute kidney injury (AKI).

METHODS AND ANALYSIS

With respect to the study schedule, over 7000 substudy eligible patients from 81 centres in 18 countries were randomised in December 2013. The authors will use a logistic regression to estimate the adjusted OR of methylprednisolone versus placebo on the primary outcome of AKI in the 14 days following surgery (a postoperative increase in serum creatinine of ≥50%, or ≥26.5 μmol/L, from the preoperative value). The stage of AKI will also be considered, as will the outcome of AKI in those with and without preoperative chronic kidney disease. After receipt of grant funding, the authors began to record additional perioperative serum creatinine measurements in consecutive patients enrolled at substudy participating centres, and patients were invited to enroll in a 6-month serum creatinine collection. In these trial subpopulations, the authors will consider the outcome of AKI defined in alternate ways, and the outcome of a 6-month change in kidney function from the preoperative value.

ETHICS AND DISSEMINATION

The authors were competitively awarded a grant from the Canadian Institutes of Health Research for this SIRS AKI substudy. Ethics approval was obtained for additional serum creatinine recordings in consecutive patients enrolled at participating centres. The additional kidney data collection first began for patients enrolled after 1 March 2012. In patients who provided consent, the last 6-month kidney outcome data will be collected in 2014. The results will be reported no later than 2015.

CLINICAL TRIAL REGISTRATION

Number NCT00427388.

Ranolazine-Induced Postrepolarization Refractoriness Suppresses Induction of Atrial Flutter and Fibrillation in Anesthetized Rabbits

Ranolazine (Ran) is a novel anti-ischemic agent with electrophysiologic properties mainly attributed to the inhibition of late Na+ current and atrial-selective early Na+ current. However, there are only limited data regarding its efficacy and mechanism of action against atrial flutter (Afl) and atrial fibrillation (AF) in intact animals. Therefore, we aimed to investigate the electrophysiologic mechanism of Ran in a rabbit model of inducible atrial tachyarrhythmias elicited by acetylcholine (ACh). Arrhythmias were produced in 19 rabbits by rapid atrial burst pacing during control, after intravenous ACh and after Ran + ACh administration. Recording of right atrial monophasic action potentials (MAPs) and programmed stimulation were utilized to determine the duration of atrial repolarization at various cycle lengths and voltage levels of action potential, including 75% of total MAP duration (MAPD75), effective refractory period (ERP), and postrepolarization refractoriness (PRR = ERP − MAPD75) prior to and after Ran. Control stimulation yielded no arrhythmias or maximal nonsustained runs of Afl/AF. Upon ACh, 17 of 19 rabbits exhibited sustained Afl and AF as well as mixed forms of Afl/AF, while 2 animals revealed none or short runs of nonsustained arrhythmias and were excluded from the study. High-frequency burst pacing during the first 30 minutes after Ran + ACh failed to induce any arrhythmia in 13 of 17 rabbits (76%), while 2 animals displayed sustained Afl/AF and 2 other animals nonsustained Afl/AF. At basic stimulation cycle length of 250 milliseconds, Ran prolonged baseline atrial ERP (80 ± 8 vs 120 ± 9 milliseconds, P < .001) much more than MAPD75 (65 ± 7 vs 85 ± 7 milliseconds, P < .001), leading to atrial PRR which was more pronounced after Ran compared with control measurements (35 ± 11 vs 15 ± 10 milliseconds, P < .001). This in vivo study demonstrates that Ran exerts antiarrhythmic activity by suppressing inducibility of ACh-mediated Afl/AF in intact rabbits. Its action may predominantly be related to a significant increase in atrial PRR, resulting in depressed electrical excitability and impediment of arrhythmia initiation.

Experimental cardiac hypertrophy induced by oral administration of mineralocorticoid and saline in rats

We suggest a new, easily applicable way of myocardial hypertrophy induction in rats. Forty randomized age-matched male Wistar rats were divided into 2 groups of 20 each: a control group and an orally administered fludrocortisone/salt group. Myocardial hypertrophy was estimated by measuring body weight, heart-weight-to-body-weight ratio and ventricular free wall thickness. Moderate myocardial hypertrophy without heart failure was established in fludrocortisone/salt group in 4 weeks. Our method is effective and low cost, and it provides a model of hypertrophic heart.

Evidence for the ''paradox'' association between hypertensive lower esophageal sphincter and gastroesophageal reflux disease

There are several studies suggesting the paradoxical simultaneous presence of hypertensive lower oesophageal sphincter and gastroesophageal reflux disease. We present a case of a 22-year-old male patient who was examined in our outpatient clinic with oesophageal food bolus impaction during a meal, severe chest pain and drooling. Manometry revealed a hypertensive lower esophageal sphincter pressure (resting pressure 35 mmHg) and pHmetry revealed a DeMeester score > 14.72 (43.27). Six months after therapy with lansoprazole, manometry revealed a normal lower oesophageal sphincter (resting pressure 14 mmHg) and the DeMeester score was < 14.72 (5.89). The patient is now asymptomatic. This report is the only published case which exhibits the normalization of lower oesophageal pressure 6 months after gastroesophageal reflux disease management with lansoprazole, thus proving and establishing the above ''paradox''.

Synchronous occurrence of a primary colon adenocarcinoma and a gastric stromal tumor. A case report

Gastrointestinal stromal tumors are currently the object of a great clinical and experimental interest. We are presenting the case of a 69-year-old patient, who was presented with lower gastrointestinal bleeding and dyspeptic symptoms over the last six months. The colonoscopy showed a large tumor of the sigmoid and the gastroscopy a large gastric tumor of the antrum, which were histologically diagnosed as colonic adenocarcinoma and gastric stromal tumor respectively. The patient underwent a sigmoidectomy and a partial gastrectomy. Six months after surgery were the clinical condition, abdominal CT, gastroscopy and colonoscopy without pathological findings. To our best knowledge, this is the second report of a synchronous gastric stromal tumor and a colonic adenocarcinoma in medical literature.

Large mesenteric gastrointestinal stromal tumor in a patient with familial adenomatous polyposis syndrome

We report a case of a 30-year-old man who presented with severe debilitation, anemia and diarrhea over two months. Colonoscopy revealed many (>100) polyps (familial adenomatous polyposis syndrome). Abdominal CT scan showed a large mass at the left upper abdomen in conjunction with the splenic flexure. Total colectomy with mesenteric mass and adjacent small bowel removal and ileoanal pouch was performed. Examination of the resected mesenteric mass showed a gastrointestinal stromal tumor (GIST) with scarce mitosis and infiltration of the adjacent small bowel. We describe for the first time in medical literature the coexistence of familial adenomatous polyposis syndrome and GIST in a 30-year-old man.