Cost-effectiveness of hydrogel plugs in CT-guided lung biopsies

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On the pc-ASPECTS scale, we deducted one or two points depending on the territory affected: right or left thalamus, cerebellum or the territory of the posterior cerebral artery (one point); any part of the midbrain or pons (two points). A score of ten indicates a normal scan. On the PMI, we divided the pons and midbrain into two territories each (left and right). We assigned one point when 50% or less of the territory was affected and two points if more than 50% of the territory was affected. A score of zero indicated a normal scan." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.F. Werner, A. López-Rueda, F.X. Zarco, J. Blasco, L San Román, S. Amaro, E. Carrero, R. Valero, L. Oleaga, J.M. Macho, N. Bargalló" "autores" => array:11 [ 0 => array:2 [ "nombre" => "M.F." "apellidos" => "Werner" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "López-Rueda" ] 2 => array:2 [ "nombre" => "F.X." "apellidos" => "Zarco" ] 3 => array:2 [ "nombre" => "J." 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"apellidos" => "Bargalló" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0033833818302157" "doi" => "10.1016/j.rx.2018.06.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0033833818302157?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173510719300187?idApp=UINPBA00004N" "url" => "/21735107/0000006100000002/v1_201903140618/S2173510719300187/v1_201903140618/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "Cost-effectiveness of hydrogel plugs in CT-guided lung biopsies" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "153" "paginaFinal" => "160" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "S.F. Marco-Doménech, P. Fernández-García, A. Navarro-Ballester, M. Cifrián-Pérez, Á. Escobar-Valero, M.V. Ibáñez-Gual" "autores" => array:6 [ 0 => array:4 [ "nombre" => "S.F." "apellidos" => "Marco-Doménech" "email" => array:1 [ 0 => "sdomenec@uji.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Fernández-García" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Navarro-Ballester" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Cifrián-Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Á." "apellidos" => "Escobar-Valero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "M.V." "apellidos" => "Ibáñez-Gual" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Radiología Diagnóstica y Terapéutica, Hospital General Universitario de Castellón, Castellón de la Plana, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad Predepartamental de Medicina, Universidad Jaume I (UJI), Castellón de la Plana, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "IMAC, Departamento de Matemáticas, Universidad Jaume I (UJI), Castellón de la Plana, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio de coste-efectividad sobre la utilización de un tapón de hidrogel en las biopsias pulmonares guiadas por tomografía computarizada" ] ] "textoCompleto" => "IntroductionThe increased use of imaging techniques in clinical practice has led to a rise in the detection of lung nodules, many of which have to be biopsied.<a class="elsevierStyleCrossRefs" href="#bib0090">1,2</a>Computed tomography (CT) guided lung biopsy can be performed using fine needle aspiration (FNA) or with a core biopsy using a tru-cut type gun, also known as a large-core needle biopsy (LCNB). Both options provide good diagnostic yields and are safe, though they are not without risks.<a class="elsevierStyleCrossRefs" href="#bib0100">3–5</a>The most common complication of lung biopsy is a pneumothorax, which may affect up to 50% of cases.<a class="elsevierStyleCrossRef" href="#bib0100">3</a> Although pneumothoraces are usually minimal and require no more than a short follow-up period, chest tubes do sometimes need to be inserted for treatment purposes.<a class="elsevierStyleCrossRefs" href="#bib0100">3,6</a> The insertion of a chest tube may be required in around 10% of CT-guided lung biopsies.<a class="elsevierStyleCrossRefs" href="#bib0120">7–9</a> Complications such as this increase the length of the patient's hospital stay and thus the biopsy costs.Multiple sealing systems have been investigated to reduce the incidence of pneumothoraces. As in studies by other authors,<a class="elsevierStyleCrossRefs" href="#bib0120">7–9</a> this study uses a dehydrated hydrogel plug which is inserted upon completion of the biopsy and expands with physiological saline solution, sealing the tract left by the needle. The use of said dehydrated hydrogel plug has reduced the incidence of pneumothoraces from 31% to 18%,<a class="elsevierStyleCrossRef" href="#bib0120">7</a> as well as the need for chest tubes from 10% to 2%.<a class="elsevierStyleCrossRef" href="#bib0130">9</a>The objective of this work is to present the first cost-effectiveness study carried out in Europe on the use of this dehydrated hydrogel plug in CT-guided lung biopsies.Material and methodsThis is a retrospective, observational, analytical study carried out on 171 CT-guided lung biopsies performed consecutively over a 10-year period (2007–2016).193 CT-guided lung biopsies performed over the course of these 10 years were included in the study. However, seven cases presented a pneumothorax during the biopsy procedure, before the hydrogel plug was inserted, and so were later excluded, as were 15 for whom images of the procedure could not be retrieved from our image filing and storage system.The study was approved by our institution's Ethics Committee and did not require patient authorisation due to its retrospective nature.The different biopsy groups were assigned according to procedure date, since the lung biopsy technique has changed over the years. Thus:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Group 1 (n=22): FNA was performed without the use of hydrogel and the procedures were carried out between 1 January 2007 and 30 April 2008.</li><li class="elsevierStyleListItem" id="lsti0010">•Group 2 (n=89): FNA was performed and hydrogel inserted upon completion of the biopsy. These procedures were carried out between 1 May 2008 and 31 December 2014.</li><li class="elsevierStyleListItem" id="lsti0015">•Group 3 (n=60): FNA and LCNB were performed, and hydrogel inserted upon completion. These procedures were carried out between 1 January 2015 and 31 December 2016. Those performed at an earlier date were also included in this group when the suspected diagnosis was metastatic breast cancer or pulmonary lymphoma, which required a histology study for diagnosis.</li></ul>For the FNA in group 1, Chiba style 20G needles (gauges) and 22G needles were used, with a co-axial technique. In groups 2 and 3, a 20G needle was used. The LCNB was performed with an automatic 20G BARD MONOPTY needle (Bard, Crawley, United Kingdom), with 11mm internal bevel displacement.Dehydrated hydrogel was inserted in the group 2 and 3 biopsies, using the Bio-Sentry™ tract sealant system (Surgical Specialties Corporation, Taunton, United Kingdom) with a 19G co-axial introducer needle (Argon Medical Devices, the Hague, Netherlands), which was used as an outer sheath in these biopsies to perform the FNA and LCNB, also with a co-axial technique.CT scans were done on the biopsied lesions in all three groups, once the biopsies were complete, in order to evaluate any immediate complications. Six hours after the biopsy, a basic chest X-ray was performed to rule out late-onset complications and, in the event of pneumothorax, the insertion of a chest tube assessed.The patients were discharged the day after the biopsy, provided there were no complications.Outcome variablesThe following variables were recorded: age, presence of emphysema in the lesion lobe, lesion diameter, skin to lesion distance, pleura to lesion distance, pneumothorax, need for a chest tube, length of hospital stay and percentage of correct diagnoses.The correct diagnosis of the biopsies was confirmed through an anatomical pathology study of the surgical specimen or clinical follow-up, since surgery was not indicated in all patients.Economic studyThis economic evaluation study was performed from the social perspective, for society as a whole, and from the health service financier's perspective, as suggested by the guidelines for structuring an economic evaluation in health care.<a class="elsevierStyleCrossRef" href="#bib0135">10</a>We performed a cost-effectiveness study in all three lung biopsy groups, analysing direct and indirect costs, without taking intangibles into account. From the social perspective, the study includes total costs, and from the health service financier's perspective, only direct costs.Although the study was performed over 10 years, we calculated the direct costs for the different biopsy types based on the costs applicable in 2017. The direct cost study took into account, on the one hand, the costs of expendable materials, according to the data provided by the financial management department of our hospital, and on the other, the cost of each procedure based on the Valencian Regional Government's Law on Fees.<a class="elsevierStyleCrossRef" href="#bib0140">11</a> Depreciation costs of the equipment were not included.Cost calculationEach group's total lung biopsy cost represents the sum of the direct costs and indirect costs.Direct costs are those resulting from the sum of costs represented by each procedure for each medical department involved (radiology and anatomical pathology), as well as the costs of the hospital stay.Indirect costs correspond to each patient's loss of productivity (days of sick leave) due to their having undergone a lung biopsy, which corresponded to the days spent in hospital.Since not all of the patients who underwent a lung biopsy were of working age, active workers were considered to be patients aged between 16 and 65 years. A weighted mean of each group's indirect costs was calculated based on whether the patients were active or passive.To calculate the indirect costs, data from the web portal of the Spanish National Institute of Statistics (Instituto Nacional de Estadística, INE) were consulted.<a class="elsevierStyleCrossRef" href="#bib0145">12</a> According to these data, in 2015 (data from the last year published), the mean annual earnings per male worker in Spain were €25,992.76 and, for female workers, €20,051.58. The quotient of these yearly salaries divided by the 365 days in a year determined each active patient's mean loss of daily earnings, as a result of undergoing a lung biopsy. For men, this amounted to €71.21/day and, for women, €54.93/day. A weighted mean of each group's indirect costs was also calculated based on whether the patients were male or female, and thus the mean indirect costs for each individual in each of the three groups were obtained.Effect calculationThe effect we wanted to measure was the “percentage of correct diagnoses” in each biopsy group.Calculation of average and incremental ratiosThe average or average cost-effectiveness ratio (ACER) indicates the cost of achieving one unit of effect in each group. The lowest average ratio is the most cost-effective option and the highest average ratio the least cost-effective option.Each group's average ratios were calculated according to the formula: average ratio=cost/effect. Each group's lung biopsy costs were used as the numerator and the effect achieved in each group as the denominator.The other numerical indicator used was the incremental cost-effectiveness ratio (ICER), through which the costs and effects of one intervention are compared with the costs and effects of another for any health problem where the results are expressed in the same units.<a class="elsevierStyleCrossRef" href="#bib0150">13</a>To compare two options—A and B—the ICER is calculated by dividing the A costs minus the B costs by the A effects minus the B effects (ICER=A Costs−B Costs/A Effects−B Effects). The ICER gives the extra cost per additional benefit unit achieved with one option versus the other.<a class="elsevierStyleCrossRef" href="#bib0150">13</a> In our case, the extra cost per percentage of correct diagnoses unit achieved with one option versus another.Statistical analysisWe performed a descriptive and inferential analysis. In the database, the individuals were split into three groups and the homogeneity of these groups was investigated in relation to the established variables. Means and standard deviations of continuous variables were calculated overall and then separately for each group. An ANOVA test was used to compare equality of means between the three groups. In cases where the ANOVA test detected significant differences between the groups, a posteriori comparisons were made to see which groups the differences lay between. For qualitative variables, the percentages in each of the three groups were calculated using a χ2 test.Results<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the patients’ ages and the characteristics of the biopsy lesions, while <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> documents complications, the length of the hospital stay and the percentages of correct diagnoses.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Cost calculation<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> details the direct, indirect and total costs.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>For the radiology department, the direct costs of the biopsies in group 1 amount to €178.48, which is the cost of a CT-guided FNA according to the Valencian Law on Fees.<a class="elsevierStyleCrossRef" href="#bib0140">11</a> In the group 2 biopsies, the hydrogel cost of €234.74 must be added to the FNA cost, yielding a total of €413.22. In the group 3 biopsies, only the automatic gun cost of €19.96 must be added to said €413.22, since the rest of the technique is exactly the same as the one used in the group 2 biopsies. This amounts to a cost of €433.18 per group 3 biopsy.Each cytology study of the material obtained in the group 1 and 2 biopsies amounts to €25.13.<a class="elsevierStyleCrossRef" href="#bib0140">11</a> In group 3, the lung histology study cost of €110.56<a class="elsevierStyleCrossRef" href="#bib0140">11</a> must be added to the €25.13 cytology study cost.The cost of one day's non-surgical hospital stay in 2017 was €310.17.<a class="elsevierStyleCrossRef" href="#bib0140">11</a> Therefore, in order to obtain the cost of the entire hospital stay, we multiplied €310.17 by the mean number of days each group spent in hospital, without their standard deviations.Thus, the direct costs used to carry out the cost-effectiveness study from the health service financier's perspective were: for a group 1 biopsy, €1261.28; for a group 2 biopsy, €1201.36; and for a group 3 biopsy, €1220.22.After calculating the weighted means in each group according to the number of biopsy patients of working age and based on whether they were male or female, we obtained indirect costs of €15.44/day for each day of sick leave taken by each group 1 patient, €27.34/day per group 2 patient, and €22.48/day per group 3 patient.Thus, the total cost of each group 1 biopsy was €1313.93; of each group 2 biopsy, €1268.61; and each group 3 biopsy, €1267.42. The total costs were those used to conduct the study from the social perspective.Effect calculationIn the group 1 biopsies, 77.3% of the diagnoses were correct; in group 2, 85.4%, and in group 3, 95% (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).Calculation of average and incremental ratiosFrom both the social perspective and the health service financier's perspective, the most costly and least effective option with the highest average ratio corresponded to the lung biopsies performed using FNA alone without hydrogel (group 1), while the most effective option which also had the lowest average ratio was FNA alongside LCNB and hydrogel (group 3). This was therefore the most cost-effective option, i.e. the one that achieved each diagnosis at the best price, and thus the dominant option versus the other two groups (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> also shows the ICERs. To calculate them, a fourth option was included in the table (group 0), which simply consists of doing nothing (no intervention), the costs and effects of which are 0. The groups have been arranged in the table from the lowest to highest cost under both perspectives. From the social perspective, the group 3 ICER versus no intervention is 13.34, i.e. each additional percentage of correct diagnosis unit gained in group 3 versus group 0 has a cost of €13.34. However, for every additional percentage of correct diagnoses unit gained in group 3 versus 2, savings of €0.12 are achieved, and €5.50 per additional percentage of correct diagnoses unit gained in group 2 versus group 1.From the health service financier's perspective, the group 2 ICER versus no intervention is €14.06 per additional percentage of correct diagnosis unit, and €1.96 per additional percentage of correct diagnoses unit in group 2 versus 3. However, savings of €2.68 are achieved per additional percentage of correct diagnoses unit gained in group 3 versus group 1.DiscussionWe performed a cost-effectiveness study on the use of a dehydrated hydrogel plug in 171 CT-guided lung biopsies. This is the first device approved by the US Food and Drug Administration to reduce the incidence of pneumothoraces and chest tube insertion after a CT-guided lung biopsy<a class="elsevierStyleCrossRef" href="#bib0120">7</a> and we wanted to see whether, as well as being effective, the use of said device was also cost-effective. To do so, we not only conducted a cost-effectiveness study from the social perspective using total costs, but also from the health service financier's perspective, using only direct costs, so that the results may be extrapolated to countries with a different social welfare system to that of Spain.Unlike in the studies conducted by other authors,<a class="elsevierStyleCrossRefs" href="#bib0120">7–9</a> the lung biopsies in our study were performed on hospital inpatients. It is therefore also interesting to assess whether the placement of a hydrogel plug had an effect on the length of hospital stay, since the longer the hospital stay, the higher the costs. Group 1 patients were in hospital for a mean of 3.41 days, which was significantly longer (p=0.033) than the 2.46 days spent by group 2 patients and the 2.10 days spent by those in group 3 (p=0.003), as well as significantly longer (p=0.003) than the group 2 and 3 mean of 2.32 days.As in this study, Zaetta et al.<a class="elsevierStyleCrossRef" href="#bib0120">7</a> observed a significant reduction in pneumothoraces among the patients in whom hydrogel plugs were used compared with the control group (18% versus 31%), as well as a reduction, albeit insignificant, in the percentage needing chest tubes (4% versus 11%). These biopsies were performed on outpatients, with only those presenting complications being admitted to hospital. A mere 9.4% of the patients with hydrogel plugs had to be admitted versus 13.6% of the control group, although these differences were not significant.Ahrar et al.<a class="elsevierStyleCrossRef" href="#bib0125">8</a> observed a significant reduction in pneumothoraces among the patients in whom hydrogel plugs were used compared with the control group (20.8% versus 32.8%; p=0.001), as well as a significant reduction in the need for chest tubes among said hydrogel patients (8.2% versus 20.8%; p<0.0001).Conversely, Grage et al.<a class="elsevierStyleCrossRef" href="#bib0130">9</a> observed an insignificant reduction in the percentage of pneumothoraces among the group with hydrogel plugs compared with the control group (29% versus 31%; p=0.498), although there was a significant reduction in the percentage of cases requiring chest tubes following said pneumothoraces (2% versus 10%; p=0.032). Biopsies on these patients were also done on an outpatient basis and only those with complications were admitted. As regards the length of hospital stay, a difference of +0.37 days was observed between the control group patients and those in whom hydrogel plugs were used.Other methods have been described to try and reduce the complications of lung biopsies. Autologous blood patching,<a class="elsevierStyleCrossRef" href="#bib0155">14</a> fibrin sealants,<a class="elsevierStyleCrossRef" href="#bib0160">15</a> collagen foam plugs and a haemostat gelatin powder paste<a class="elsevierStyleCrossRef" href="#bib0165">16</a> have also been used.The use of haemostat gelatin powder paste achieved a pneumothorax rate of 8.8% and only 4% of the patients who used it required a chest tube. The differences were significant for pneumothoraces, but not chest tubes, although a significant reduction in procedure costs was observed in the patients who used haemostat paste versus those who did not.<a class="elsevierStyleCrossRef" href="#bib0165">16</a>Moreover, all of these alternative methods<a class="elsevierStyleCrossRefs" href="#bib0155">14–16</a> are operator-dependent, since the sealant needs to be prepared prior to use. The use of dehydrated hydrogel, on the other hand, is standardised and reproducible, because the sealant comes ready-prepared and only needs to be inserted via the working channel upon completion of the biopsy.In this study, from both the social perspective and health service financier's perspective, the most cost-effective option was group 3, as it had the lowest average ratio. On using the ICER, we can see that from the social perspective there is a saving of €0.12 per additional percentage of correct diagnoses unit in group 3 versus group 2; from the health service financier's perspective, there is a saving of €2.68 per additional percentage of correct diagnoses unit in group 3 versus group 1.Moreover, the group 3 patients had fewer pneumothoraces than those in group 1 (p=0.024), required fewer chest tubes than group 2 (p=0.0059) and had a shorter hospital stay than group 1 (p=0.003). They also had significantly more correct diagnoses than group 1 (p=0.04) and almost significantly more (p=0.11) than group 2.It would be logical to assume that the demand for lung biopsies will increase in the future, as with other organ biopsies,<a class="elsevierStyleCrossRef" href="#bib0170">17</a> and while the cost saving in each biopsy may be small, large savings could be achieved if they are taken into account as a whole.There are several limitations to this study. It was a retrospective study in which cases were recruited in order of arrival and not randomised. Said cases came from a single site and were relatively low in number. Moreover, seven cases were excluded who had a pneumothorax during the biopsy procedure, before the hydrogel plug was inserted, which could have altered the effectiveness of the hydrogel plug in the results obtained. We also did not evaluate the number of cylinders obtained in each biopsy or the haemorrhagic complications. New prospective, randomised, multicentre studies will thus be required to confirm the utility of hydrogel plugs.In conclusion, we believe the use of dehydrated hydrogel in CT-guided lung biopsies to be safe and simple, and that it significantly reduces the percentage of patients with pneumothoraces, as well as the length of their hospital stay, thus making the use of hydrogel plugs in combination with FNA and LCNB the most cost-effective option in the performance of CT-guided lung biopsies.Authorship<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">1.Responsible for study integrity: SFMD and PFG.</li><li class="elsevierStyleListItem" id="lsti0025">2.Study conception: SFMD and PFG.</li><li class="elsevierStyleListItem" id="lsti0030">3.Study design: SFMD, PFG and MVIG.</li><li class="elsevierStyleListItem" id="lsti0035">4.Data acquisition: SFMD, PFG, ANB, MCP and AEV.</li><li class="elsevierStyleListItem" id="lsti0040">5.Data analysis and interpretation: SFMD, PFG and MVIG.</li><li class="elsevierStyleListItem" id="lsti0045">6.Statistical processing: SFMD and MVIG.</li><li class="elsevierStyleListItem" id="lsti0050">7.Literature search: SFMD, PFG, ANB and MCP.</li><li class="elsevierStyleListItem" id="lsti0055">8.Composition of the article: SFMD, PFG, ANB, MCP, AEV and MVIG.</li><li class="elsevierStyleListItem" id="lsti0060">9.Critical review of the manuscript with intellectually relevant contributions: SFMD, PFG and MVIG.</li><li class="elsevierStyleListItem" id="lsti0065">10.Approval of the final version: SFMD, PFG, ANB, MCP, AEV and MVIG.</li></ul>Conflicts of interestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1163678" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1089253" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1163679" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1089254" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Outcome variables" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Economic study" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Cost calculation" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Effect calculation" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Calculation of average and incremental ratios" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0045" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Cost calculation" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Effect calculation" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Calculation of average and incremental ratios" ] ] ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Authorship" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-08-25" "fechaAceptado" => "2019-01-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1089253" "palabras" => array:5 [ 0 => "Cost-effectiveness" 1 => "Lung biopsy" 2 => "Fine-needle aspiration" 3 => "Core-needle biopsy" 4 => "Hydrogel plug" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1089254" "palabras" => array:5 [ 0 => "Coste-efectividad" 1 => "Biopsia pulmonar" 2 => "Punción aspirativa con aguja fina" 3 => "Biopsia con aguja gruesa" 4 => "Tapón de hidrogel" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveUsing a hydrogel plug decreases the number of cases of pneumothorax and reduces the need for pleural drainage tubes in CT-guided lung biopsies. We aimed to analyse the cost-effectiveness of using hydrogel plugs. Material and methodsWe analysed 171 lung biopsies divided into three groups: Group 1 (n=22): fine-needle aspiration cytology (FNAC) without hydrogel plugs; Group 2 (n=89): FNAC with hydrogel plugs; and Group 3 (n=60): FNAC plus core-needle biopsy (CNB) with hydrogel plugs. We calculated the total costs (direct and indirect) in the three groups. We analysed the percentage of correct diagnoses, the average and incremental rations, and the most cost-effective option. ResultsTotal costs: Group 1=1261.28+52.65=€1313.93; Group 2=1201.36+67.25=€1268.61; Group 3=1220.22+47.20=€1267.42. Percentage of correct diagnoses: Group 1=77.3%, Group 2=85.4%, and Group 3=95% (p=0.04). Average cost-effectiveness ratio: Group 1=16.99; Group 2=14.85; and Group 3=13.34. ConclusionsGroup 3 was the best option, with the lowest average cost-effectiveness ratio; therefore, the most cost-effective approach is to do FNAC and CNB using a dehydrated hydrogel plug at the end of the procedure." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoLa utilización de un tapón de hidrogel reduce el número de neumotórax y la necesidad de tubos de drenaje pleural en las biopsias de pulmón guiadas por tomografía computarizada. Realizamos un estudio de coste-efectividad sobre su uso. Material y métodosSe analizaron 171 biopsias de pulmón divididas en tres grupos: grupo 1 (n=22): punción aspirativa con aguja fina (PAAF) sin tapón de hidrogel; grupo 2 (n=89): PAAF con tapón, y grupo 3 (n=60): PAAF más biopsia con aguja gruesa (BAG) con tapón. Se calcularon costes totales (directos e indirectos) de los tres grupos. Se analizó el porcentaje de diagnósticos correctos, las ratios medias e incrementales y la opción más coste-efectiva. ResultadosCostes totales: grupo 1=1.261,28+52,65=1.313,93 €, grupo 2=1.201,36+67,25=1.268,61 €, grupo 3=1.220,22+47,20=1.267,42 €. Porcentaje de diagnósticos correctos: grupo 1=77,3%, grupo 2=85,4% y grupo 3=95% (p=0,04). Ratio medio de coste-efectividad: grupo 1=16,99, grupo 2=14,85 y grupo 3=13,34. ConclusionesEl grupo 3 fue la opción dominante, con la menor ratio media, lo cual demuestra que, en las biopsias de pulmón guiadas por TC, la opción más coste-efectiva es la realización de una PAAF y una BAG con la utilización del tapón de hidrogel deshidratado al final del procedimiento." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Marco-Doménech SF, Fernández-García P, Navarro-Ballester A, Cifrián-Pérez M, Escobar-Valero Á, Ibáñez-Gual MV. Estudio de coste-efectividad sobre la utilización de un tapón de hidrogel en las biopsias pulmonares guiadas por tomografía computarizada. Radiología. 2019;61:153–160." ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Overall=sum of the three groups; m±SD=mean±standard deviation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Overall \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 3 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Groups 2 and 3 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Age (m±SD)</td><td class="td" title="table-entry " rowspan="3" align="left" valign="top">68.13±11.66</td><td class="td" title="table-entry " align="left" valign="top">71.18±12.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66.85±12.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">68.90±10.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">67.68±11.45 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – group 2 – group 3): 0.244</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – groups 2 and 3): 0.238</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Pulmonary emphysema (%)</td><td class="td" title="table-entry " rowspan="3" align="left" valign="top">25.15%</td><td class="td" title="table-entry " align="left" valign="top">22.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21.7% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25.5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – group 2 – group 3): 0.64</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – groups 2 and 3): 0.98</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Lesion diameter (m±SD)</td><td class="td" title="table-entry " rowspan="4" align="left" valign="top">29.95±13.35</td><td class="td" title="table-entry " align="left" valign="top">39.64±15.87 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28.17±13.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28.98±9.91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28.50±12.35 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – group 2 – group 3): 0.0009</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value Group 2 – group 1: 0.0007 Group 3 – group 1: 0.003 Group 3 – group 2: 0.923</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – groups 2 and 3): 0.004</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Skin-lesion distance (m±SD)</td><td class="td" title="table-entry " rowspan="3" align="left" valign="top">65.11±22.7</td><td class="td" title="table-entry " align="left" valign="top">64.95±26.38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64.61±22.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65.88±22.63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65.14±22.20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – group 2 – group 3): 0.946</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – groups 2 and 3): 0.975</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Pleura-lesion distance (m±SD)</td><td class="td" title="table-entry " rowspan="4" align="left" valign="top">24.22±17.82</td><td class="td" title="table-entry " align="left" valign="top">31.45±20.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25.42±17.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20.40±16.91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23.36±17.21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – group 2 – group 3): 0.0332</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value Group 2 – group 1: 0.31 Group 3 – group 1: 0.03 Group 3 – group 2: 0.20</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – groups 2 and 3): 0.09</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1986222.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patients’ ages and characteristics of the biopsy lesions." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "m±SD=mean±standard deviation." "tablatextoimagen" => array:4 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Pneumothorax (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Overall \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Group 1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Group 2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Group 3 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Groups 2 and 3 \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">30.99% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">54.5% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">29.2% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">25% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">27.5% \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – group 2 – group 3): 0.03</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – group 3): 0.024 p value (group 1 – group 2): 0.046 p value (group 2 – group 3): 0.71</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – groups 2 and 3): 0.02</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1986220.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Chest tube (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">7.02% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">9.1% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">11.2% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">0% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">6.7% \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – group 2 – group 3): 0.029</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – group 3): 0.07 p value (group 1 – group 2): 1 p value (group 2 – group 3): 0.0059</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – groups 2 and 3): 0.65</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1986219.png" ] ] 2 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Length of hospital stay (days) (m±SD) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2.46±1.63 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3.41±3.26 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2.46±1.43 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2.10±0.60 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2.32±1.18 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – group 2 – group 3): 0.005</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value p value (group 2 – group 1): 0.033 p value (group 3 – group 1): 0.003 p value (group 3 – group 2): 0.359</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – groups 2 and 3): 0.003</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1986218.png" ] ] 3 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correct diagnoses (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">87.72% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">77.3% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">85.4% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">89.3% \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – group 2 – group 3): 0.04a</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – group 3): 0.04 p value (group 1 – group 2): 0.55 p value (group 2 – group 3): 0.11</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="4" align="left" valign="top">p value (group 1 – groups 2 and 3): 0.15<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a></td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1986221.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Fisher's exact test." ] ] ] "descripcion" => array:1 [ "en" => "Complications, length of hospital stay and percentage of correct diagnoses in the different biopsy groups." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Cyto.=cytology; histo.=histology; FNA: fine needle aspiration." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 3 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Direct costs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Radiology Department</td><td class="td" title="table-entry " rowspan="3" align="left" valign="top">FNA=€178.48</td><td class="td" title="table-entry " align="left" valign="top">FNA=€178.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">FNA=€178.48 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Hydrogel=€234.74</td><td class="td" title="table-entry " align="left" valign="top">Tru-cut needle=€19.96 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hydrogel=€234.74 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Anatomical Pathology Department</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Cyto.=€25.13</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Cyto.=€25.13</td><td class="td" title="table-entry " align="left" valign="top">Cyto.=€25.13 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Histo.=€110.56 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Length of stay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.41 days×€310.17=€1057.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.46 days×€310.17=€763.01 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.10 days×€310.17=€651.35 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">€1261.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">€1201.36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">€1220.22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Indirect costs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.41 days×€15.44/day=€52.65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.46 days×€27.34/day=€67.25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.10 days×€22.48/day=€47.20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total costs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">€1313.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">€1268.61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">€1267.42 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1986223.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Costs for the different biopsy groups." ] ] 3 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ΔCosts=cost increase with respect to the previous group; ΔEffects=effect increase with respect to the previous group; ICER=incremental cost-effectiveness ratio; ACER=average cost-effectiveness ratio." "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="7" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Social perspective</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total costs \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Effect \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ACER \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Δ Costs \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Δ Effects \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ICER \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1267.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1267.42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.34 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1268.61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−9.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1313.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−8.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−5.59 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1986217.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="7" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Health service financier's perspective</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Direct costs \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Effect \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ACER \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ΔCosts \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ΔEffects \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ICER \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1201.36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1201.36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.06 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1220.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.96 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1261.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−17.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−2.68 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1986216.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Summary table of the different groups’ costs, effects and cost-effectiveness analysis from the social perspective and the health service financier's perspective, arranged from the lowest to highest cost." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0090" "etiqueta" => "1" 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Estudio de coste-efectividad sobre la utilización de un tapón de hidrogel en las biopsias pulmonares guiadas por tomografía computarizada

S.F. Marco-Doménecha,b,

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sdomenec@uji.es

Corresponding author.

, P. Fernández-Garcíaa,b, A. Navarro-Ballestera, M. Cifrián-Péreza, Á. Escobar-Valerob, M.V. Ibáñez-Gualc

a Servicio de Radiología Diagnóstica y Terapéutica, Hospital General Universitario de Castellón, Castellón de la Plana, Spain

b Unidad Predepartamental de Medicina, Universidad Jaume I (UJI), Castellón de la Plana, Spain

c IMAC, Departamento de Matemáticas, Universidad Jaume I (UJI), Castellón de la Plana, Spain

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            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "IMAC&#44; Departamento de Matem&#225;ticas&#44; Universidad Jaume I &#40;UJI&#41;&#44; Castell&#243;n de la Plana&#44; Spain"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Estudio de coste-efectividad sobre la utilizaci&#243;n de un tap&#243;n de hidrogel en las biopsias pulmonares guiadas por tomograf&#237;a computarizada"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The increased use of imaging techniques in clinical practice has led to a rise in the detection of lung nodules&#44; many of which have to be biopsied&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Computed tomography &#40;CT&#41; guided lung biopsy can be performed using fine needle aspiration &#40;FNA&#41; or with a core biopsy using a tru-cut type gun&#44; also known as a large-core needle biopsy &#40;LCNB&#41;&#46; Both options provide good diagnostic yields and are safe&#44; though they are not without risks&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The most common complication of lung biopsy is a pneumothorax&#44; which may affect up to 50&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> Although pneumothoraces are usually minimal and require no more than a short follow-up period&#44; chest tubes do sometimes need to be inserted for treatment purposes&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#44;6</span></a> The insertion of a chest tube may be required in around 10&#37; of CT-guided lung biopsies&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#8211;9</span></a> Complications such as this increase the length of the patient&#39;s hospital stay and thus the biopsy costs&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Multiple sealing systems have been investigated to reduce the incidence of pneumothoraces&#46; As in studies by other authors&#44;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#8211;9</span></a> this study uses a dehydrated hydrogel plug which is inserted upon completion of the biopsy and expands with physiological saline solution&#44; sealing the tract left by the needle&#46; The use of said dehydrated hydrogel plug has reduced the incidence of pneumothoraces from 31&#37; to 18&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> as well as the need for chest tubes from 10&#37; to 2&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The objective of this work is to present the first cost-effectiveness study carried out in Europe on the use of this dehydrated hydrogel plug in CT-guided lung biopsies&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">This is a retrospective&#44; observational&#44; analytical study carried out on 171 CT-guided lung biopsies performed consecutively over a 10-year period &#40;2007&#8211;2016&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">193 CT-guided lung biopsies performed over the course of these 10 years were included in the study&#46; However&#44; seven cases presented a pneumothorax during the biopsy procedure&#44; before the hydrogel plug was inserted&#44; and so were later excluded&#44; as were 15 for whom images of the procedure could not be retrieved from our image filing and storage system&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The study was approved by our institution&#39;s Ethics Committee and did not require patient authorisation due to its retrospective nature&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The different biopsy groups were assigned according to procedure date&#44; since the lung biopsy technique has changed over the years&#46; Thus&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Group 1 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&#58; FNA was performed without the use of hydrogel and the procedures were carried out between 1 January 2007 and 30 April 2008&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Group 2 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>89&#41;&#58; FNA was performed and hydrogel inserted upon completion of the biopsy&#46; These procedures were carried out between 1 May 2008 and 31 December 2014&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Group 3 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>60&#41;&#58; FNA and LCNB were performed&#44; and hydrogel inserted upon completion&#46; These procedures were carried out between 1 January 2015 and 31 December 2016&#46; Those performed at an earlier date were also included in this group when the suspected diagnosis was metastatic breast cancer or pulmonary lymphoma&#44; which required a histology study for diagnosis&#46;</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">For the FNA in group 1&#44; Chiba style 20<span class="elsevierStyleHsp" style=""></span>G needles &#40;gauges&#41; and 22<span class="elsevierStyleHsp" style=""></span>G needles were used&#44; with a co-axial technique&#46; In groups 2 and 3&#44; a 20<span class="elsevierStyleHsp" style=""></span>G needle was used&#46; The LCNB was performed with an automatic 20<span class="elsevierStyleHsp" style=""></span>G BARD MONOPTY needle &#40;Bard&#44; Crawley&#44; United Kingdom&#41;&#44; with 11<span class="elsevierStyleHsp" style=""></span>mm internal bevel displacement&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Dehydrated hydrogel was inserted in the group 2 and 3 biopsies&#44; using the Bio-Sentry&#8482; tract sealant system &#40;Surgical Specialties Corporation&#44; Taunton&#44; United Kingdom&#41; with a 19<span class="elsevierStyleHsp" style=""></span>G co-axial introducer needle &#40;Argon Medical Devices&#44; the Hague&#44; Netherlands&#41;&#44; which was used as an outer sheath in these biopsies to perform the FNA and LCNB&#44; also with a co-axial technique&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">CT scans were done on the biopsied lesions in all three groups&#44; once the biopsies were complete&#44; in order to evaluate any immediate complications&#46; Six hours after the biopsy&#44; a basic chest X-ray was performed to rule out late-onset complications and&#44; in the event of pneumothorax&#44; the insertion of a chest tube assessed&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The patients were discharged the day after the biopsy&#44; provided there were no complications&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Outcome variables</span><p id="par0085" class="elsevierStylePara elsevierViewall">The following variables were recorded&#58; age&#44; presence of emphysema in the lesion lobe&#44; lesion diameter&#44; skin to lesion distance&#44; pleura to lesion distance&#44; pneumothorax&#44; need for a chest tube&#44; length of hospital stay and percentage of correct diagnoses&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The correct diagnosis of the biopsies was confirmed through an anatomical pathology study of the surgical specimen or clinical follow-up&#44; since surgery was not indicated in all patients&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Economic study</span><p id="par0095" class="elsevierStylePara elsevierViewall">This economic evaluation study was performed from the social perspective&#44; for society as a whole&#44; and from the health service financier&#39;s perspective&#44; as suggested by the guidelines for structuring an economic evaluation in health care&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">We performed a cost-effectiveness study in all three lung biopsy groups&#44; analysing direct and indirect costs&#44; without taking intangibles into account&#46; From the social perspective&#44; the study includes total costs&#44; and from the health service financier&#39;s perspective&#44; only direct costs&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Although the study was performed over 10 years&#44; we calculated the direct costs for the different biopsy types based on the costs applicable in 2017&#46; The direct cost study took into account&#44; on the one hand&#44; the costs of expendable materials&#44; according to the data provided by the financial management department of our hospital&#44; and on the other&#44; the cost of each procedure based on the Valencian Regional Government&#39;s Law on Fees&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> Depreciation costs of the equipment were not included&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Cost calculation</span><p id="par0110" class="elsevierStylePara elsevierViewall">Each group&#39;s total lung biopsy cost represents the sum of the direct costs and indirect costs&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Direct costs are those resulting from the sum of costs represented by each procedure for each medical department involved &#40;radiology and anatomical pathology&#41;&#44; as well as the costs of the hospital stay&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Indirect costs correspond to each patient&#39;s loss of productivity &#40;days of sick leave&#41; due to their having undergone a lung biopsy&#44; which corresponded to the days spent in hospital&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Since not all of the patients who underwent a lung biopsy were of working age&#44; active workers were considered to be patients aged between 16 and 65 years&#46; A weighted mean of each group&#39;s indirect costs was calculated based on whether the patients were active or passive&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">To calculate the indirect costs&#44; data from the web portal of the Spanish National Institute of Statistics &#40;<span class="elsevierStyleItalic">Instituto Nacional de Estad&#237;stica&#44; INE</span>&#41; were consulted&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> According to these data&#44; in 2015 &#40;data from the last year published&#41;&#44; the mean annual earnings per male worker in Spain were &#8364;25&#44;992&#46;76 and&#44; for female workers&#44; &#8364;20&#44;051&#46;58&#46; The quotient of these yearly salaries divided by the 365 days in a year determined each active patient&#39;s mean loss of daily earnings&#44; as a result of undergoing a lung biopsy&#46; For men&#44; this amounted to &#8364;71&#46;21&#47;day and&#44; for women&#44; &#8364;54&#46;93&#47;day&#46; A weighted mean of each group&#39;s indirect costs was also calculated based on whether the patients were male or female&#44; and thus the mean indirect costs for each individual in each of the three groups were obtained&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Effect calculation</span><p id="par0135" class="elsevierStylePara elsevierViewall">The effect we wanted to measure was the &#8220;percentage of correct diagnoses&#8221; in each biopsy group&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Calculation of average and incremental ratios</span><p id="par0140" class="elsevierStylePara elsevierViewall">The average or average cost-effectiveness ratio &#40;ACER&#41; indicates the cost of achieving one unit of effect in each group&#46; The lowest average ratio is the most cost-effective option and the highest average ratio the least cost-effective option&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Each group&#39;s average ratios were calculated according to the formula&#58; average ratio<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>cost&#47;effect&#46; Each group&#39;s lung biopsy costs were used as the numerator and the effect achieved in each group as the denominator&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The other numerical indicator used was the incremental cost-effectiveness ratio &#40;ICER&#41;&#44; through which the costs and effects of one intervention are compared with the costs and effects of another for any health problem where the results are expressed in the same units&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">To compare two options&#8212;A and B&#8212;the ICER is calculated by dividing the A costs minus the B costs by the A effects minus the B effects &#40;ICER<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>A Costs<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>B Costs&#47;A Effects<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>B Effects&#41;&#46; The ICER gives the extra cost per additional benefit unit achieved with one option versus the other&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> In our case&#44; the extra cost per percentage of correct diagnoses unit achieved with one option versus another&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0160" class="elsevierStylePara elsevierViewall">We performed a descriptive and inferential analysis&#46; In the database&#44; the individuals were split into three groups and the homogeneity of these groups was investigated in relation to the established variables&#46; Means and standard deviations of continuous variables were calculated overall and then separately for each group&#46; An ANOVA test was used to compare equality of means between the three groups&#46; In cases where the ANOVA test detected significant differences between the groups&#44; a posteriori comparisons were made to see which groups the differences lay between&#46; For qualitative variables&#44; the percentages in each of the three groups were calculated using a <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0165" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the patients&#8217; ages and the characteristics of the biopsy lesions&#44; while <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> documents complications&#44; the length of the hospital stay and the percentages of correct diagnoses&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Cost calculation</span><p id="par0170" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> details the direct&#44; indirect and total costs&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">For the radiology department&#44; the direct costs of the biopsies in group 1 amount to &#8364;178&#46;48&#44; which is the cost of a CT-guided FNA according to the Valencian Law on Fees&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> In the group 2 biopsies&#44; the hydrogel cost of &#8364;234&#46;74 must be added to the FNA cost&#44; yielding a total of &#8364;413&#46;22&#46; In the group 3 biopsies&#44; only the automatic gun cost of &#8364;19&#46;96 must be added to said &#8364;413&#46;22&#44; since the rest of the technique is exactly the same as the one used in the group 2 biopsies&#46; This amounts to a cost of &#8364;433&#46;18 per group 3 biopsy&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Each cytology study of the material obtained in the group 1 and 2 biopsies amounts to &#8364;25&#46;13&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> In group 3&#44; the lung histology study cost of &#8364;110&#46;56<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> must be added to the &#8364;25&#46;13 cytology study cost&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The cost of one day&#39;s non-surgical hospital stay in 2017 was &#8364;310&#46;17&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a> Therefore&#44; in order to obtain the cost of the entire hospital stay&#44; we multiplied &#8364;310&#46;17 by the mean number of days each group spent in hospital&#44; without their standard deviations&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Thus&#44; the direct costs used to carry out the cost-effectiveness study from the health service financier&#39;s perspective were&#58; for a group 1 biopsy&#44; &#8364;1261&#46;28&#59; for a group 2 biopsy&#44; &#8364;1201&#46;36&#59; and for a group 3 biopsy&#44; &#8364;1220&#46;22&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">After calculating the weighted means in each group according to the number of biopsy patients of working age and based on whether they were male or female&#44; we obtained indirect costs of &#8364;15&#46;44&#47;day for each day of sick leave taken by each group 1 patient&#44; &#8364;27&#46;34&#47;day per group 2 patient&#44; and &#8364;22&#46;48&#47;day per group 3 patient&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Thus&#44; the total cost of each group 1 biopsy was &#8364;1313&#46;93&#59; of each group 2 biopsy&#44; &#8364;1268&#46;61&#59; and each group 3 biopsy&#44; &#8364;1267&#46;42&#46; The total costs were those used to conduct the study from the social perspective&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Effect calculation</span><p id="par0205" class="elsevierStylePara elsevierViewall">In the group 1 biopsies&#44; 77&#46;3&#37; of the diagnoses were correct&#59; in group 2&#44; 85&#46;4&#37;&#44; and in group 3&#44; 95&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Calculation of average and incremental ratios</span><p id="par0210" class="elsevierStylePara elsevierViewall">From both the social perspective and the health service financier&#39;s perspective&#44; the most costly and least effective option with the highest average ratio corresponded to the lung biopsies performed using FNA alone without hydrogel &#40;group 1&#41;&#44; while the most effective option which also had the lowest average ratio was FNA alongside LCNB and hydrogel &#40;group 3&#41;&#46; This was therefore the most cost-effective option&#44; i&#46;e&#46; the one that achieved each diagnosis at the best price&#44; and thus the dominant option versus the other two groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> also shows the ICERs&#46; To calculate them&#44; a fourth option was included in the table &#40;group 0&#41;&#44; which simply consists of doing nothing &#40;no intervention&#41;&#44; the costs and effects of which are 0&#46; The groups have been arranged in the table from the lowest to highest cost under both perspectives&#46; From the social perspective&#44; the group 3 ICER versus no intervention is 13&#46;34&#44; i&#46;e&#46; each additional percentage of correct diagnosis unit gained in group 3 versus group 0 has a cost of &#8364;13&#46;34&#46; However&#44; for every additional percentage of correct diagnoses unit gained in group 3 versus 2&#44; savings of &#8364;0&#46;12 are achieved&#44; and &#8364;5&#46;50 per additional percentage of correct diagnoses unit gained in group 2 versus group 1&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">From the health service financier&#39;s perspective&#44; the group 2 ICER versus no intervention is &#8364;14&#46;06 per additional percentage of correct diagnosis unit&#44; and &#8364;1&#46;96 per additional percentage of correct diagnoses unit in group 2 versus 3&#46; However&#44; savings of &#8364;2&#46;68 are achieved per additional percentage of correct diagnoses unit gained in group 3 versus group 1&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Discussion</span><p id="par0225" class="elsevierStylePara elsevierViewall">We performed a cost-effectiveness study on the use of a dehydrated hydrogel plug in 171 CT-guided lung biopsies&#46; This is the first device approved by the US Food and Drug Administration to reduce the incidence of pneumothoraces and chest tube insertion after a CT-guided lung biopsy<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> and we wanted to see whether&#44; as well as being effective&#44; the use of said device was also cost-effective&#46; To do so&#44; we not only conducted a cost-effectiveness study from the social perspective using total costs&#44; but also from the health service financier&#39;s perspective&#44; using only direct costs&#44; so that the results may be extrapolated to countries with a different social welfare system to that of Spain&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Unlike in the studies conducted by other authors&#44;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">7&#8211;9</span></a> the lung biopsies in our study were performed on hospital inpatients&#46; It is therefore also interesting to assess whether the placement of a hydrogel plug had an effect on the length of hospital stay&#44; since the longer the hospital stay&#44; the higher the costs&#46; Group 1 patients were in hospital for a mean of 3&#46;41 days&#44; which was significantly longer &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;033&#41; than the 2&#46;46 days spent by group 2 patients and the 2&#46;10 days spent by those in group 3 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#44; as well as significantly longer &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41; than the group 2 and 3 mean of 2&#46;32 days&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">As in this study&#44; Zaetta et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> observed a significant reduction in pneumothoraces among the patients in whom hydrogel plugs were used compared with the control group &#40;18&#37; versus 31&#37;&#41;&#44; as well as a reduction&#44; albeit insignificant&#44; in the percentage needing chest tubes &#40;4&#37; versus 11&#37;&#41;&#46; These biopsies were performed on outpatients&#44; with only those presenting complications being admitted to hospital&#46; A mere 9&#46;4&#37; of the patients with hydrogel plugs had to be admitted versus 13&#46;6&#37; of the control group&#44; although these differences were not significant&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Ahrar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> observed a significant reduction in pneumothoraces among the patients in whom hydrogel plugs were used compared with the control group &#40;20&#46;8&#37; versus 32&#46;8&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; as well as a significant reduction in the need for chest tubes among said hydrogel patients &#40;8&#46;2&#37; versus 20&#46;8&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Conversely&#44; Grage et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> observed an insignificant reduction in the percentage of pneumothoraces among the group with hydrogel plugs compared with the control group &#40;29&#37; versus 31&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;498&#41;&#44; although there was a significant reduction in the percentage of cases requiring chest tubes following said pneumothoraces &#40;2&#37; versus 10&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;032&#41;&#46; Biopsies on these patients were also done on an outpatient basis and only those with complications were admitted&#46; As regards the length of hospital stay&#44; a difference of &#43;0&#46;37 days was observed between the control group patients and those in whom hydrogel plugs were used&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Other methods have been described to try and reduce the complications of lung biopsies&#46; Autologous blood patching&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> fibrin sealants&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> collagen foam plugs and a haemostat gelatin powder paste<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a> have also been used&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">The use of haemostat gelatin powder paste achieved a pneumothorax rate of 8&#46;8&#37; and only 4&#37; of the patients who used it required a chest tube&#46; The differences were significant for pneumothoraces&#44; but not chest tubes&#44; although a significant reduction in procedure costs was observed in the patients who used haemostat paste versus those who did not&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Moreover&#44; all of these alternative methods<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">14&#8211;16</span></a> are operator-dependent&#44; since the sealant needs to be prepared prior to use&#46; The use of dehydrated hydrogel&#44; on the other hand&#44; is standardised and reproducible&#44; because the sealant comes ready-prepared and only needs to be inserted via the working channel upon completion of the biopsy&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">In this study&#44; from both the social perspective and health service financier&#39;s perspective&#44; the most cost-effective option was group 3&#44; as it had the lowest average ratio&#46; On using the ICER&#44; we can see that from the social perspective there is a saving of &#8364;0&#46;12 per additional percentage of correct diagnoses unit in group 3 versus group 2&#59; from the health service financier&#39;s perspective&#44; there is a saving of &#8364;2&#46;68 per additional percentage of correct diagnoses unit in group 3 versus group 1&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Moreover&#44; the group 3 patients had fewer pneumothoraces than those in group 1 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;024&#41;&#44; required fewer chest tubes than group 2 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0059&#41; and had a shorter hospital stay than group 1 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#46; They also had significantly more correct diagnoses than group 1 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41; and almost significantly more &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;11&#41; than group 2&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">It would be logical to assume that the demand for lung biopsies will increase in the future&#44; as with other organ biopsies&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a> and while the cost saving in each biopsy may be small&#44; large savings could be achieved if they are taken into account as a whole&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">There are several limitations to this study&#46; It was a retrospective study in which cases were recruited in order of arrival and not randomised&#46; Said cases came from a single site and were relatively low in number&#46; Moreover&#44; seven cases were excluded who had a pneumothorax during the biopsy procedure&#44; before the hydrogel plug was inserted&#44; which could have altered the effectiveness of the hydrogel plug in the results obtained&#46; We also did not evaluate the number of cylinders obtained in each biopsy or the haemorrhagic complications&#46; New prospective&#44; randomised&#44; multicentre studies will thus be required to confirm the utility of hydrogel plugs&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">In conclusion&#44; we believe the use of dehydrated hydrogel in CT-guided lung biopsies to be safe and simple&#44; and that it significantly reduces the percentage of patients with pneumothoraces&#44; as well as the length of their hospital stay&#44; thus making the use of hydrogel plugs in combination with FNA and LCNB the most cost-effective option in the performance of CT-guided lung biopsies&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Authorship</span><p id="par0290" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1&#46;</span><p id="par0295" class="elsevierStylePara elsevierViewall">Responsible for study integrity&#58; SFMD and PFG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2&#46;</span><p id="par0300" class="elsevierStylePara elsevierViewall">Study conception&#58; SFMD and PFG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">3&#46;</span><p id="par0305" class="elsevierStylePara elsevierViewall">Study design&#58; SFMD&#44; PFG and MVIG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">4&#46;</span><p id="par0310" class="elsevierStylePara elsevierViewall">Data acquisition&#58; SFMD&#44; PFG&#44; ANB&#44; MCP and AEV&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">5&#46;</span><p id="par0315" class="elsevierStylePara elsevierViewall">Data analysis and interpretation&#58; SFMD&#44; PFG and MVIG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">6&#46;</span><p id="par0320" class="elsevierStylePara elsevierViewall">Statistical processing&#58; SFMD and MVIG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">7&#46;</span><p id="par0325" class="elsevierStylePara elsevierViewall">Literature search&#58; SFMD&#44; PFG&#44; ANB and MCP&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">8&#46;</span><p id="par0330" class="elsevierStylePara elsevierViewall">Composition of the article&#58; SFMD&#44; PFG&#44; ANB&#44; MCP&#44; AEV and MVIG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">9&#46;</span><p id="par0335" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant contributions&#58; SFMD&#44; PFG and MVIG&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">10&#46;</span><p id="par0340" class="elsevierStylePara elsevierViewall">Approval of the final version&#58; SFMD&#44; PFG&#44; ANB&#44; MCP&#44; AEV and MVIG&#46;</p></li></ul></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0345" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Using a hydrogel plug decreases the number of cases of pneumothorax and reduces the need for pleural drainage tubes in CT-guided lung biopsies&#46; We aimed to analyse the cost-effectiveness of using hydrogel plugs&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We analysed 171 lung biopsies divided into three groups&#58; Group 1 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&#58; fine-needle aspiration cytology &#40;FNAC&#41; without hydrogel plugs&#59; Group 2 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>89&#41;&#58; FNAC with hydrogel plugs&#59; and Group 3 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>60&#41;&#58; FNAC plus core-needle biopsy &#40;CNB&#41; with hydrogel plugs&#46; We calculated the total costs &#40;direct and indirect&#41; in the three groups&#46; We analysed the percentage of correct diagnoses&#44; the average and incremental rations&#44; and the most cost-effective option&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Total costs&#58; Group 1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1261&#46;28<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>52&#46;65<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;1313&#46;93&#59; Group 2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1201&#46;36<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>67&#46;25<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;1268&#46;61&#59; Group 3<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1220&#46;22<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>47&#46;20<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;1267&#46;42&#46; Percentage of correct diagnoses&#58; Group 1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>77&#46;3&#37;&#44; Group 2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>85&#46;4&#37;&#44; and Group 3<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>95&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#46; Average cost-effectiveness ratio&#58; Group 1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#46;99&#59; Group 2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#46;85&#59; and Group 3<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#46;34&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Group 3 was the best option&#44; with the lowest average cost-effectiveness ratio&#59; therefore&#44; the most cost-effective approach is to do FNAC and CNB using a dehydrated hydrogel plug at the end of the procedure&#46;</p></span>"
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            "titulo" => "Objective"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La utilizaci&#243;n de un tap&#243;n de hidrogel reduce el n&#250;mero de neumot&#243;rax y la necesidad de tubos de drenaje pleural en las biopsias de pulm&#243;n guiadas por tomograf&#237;a computarizada&#46; Realizamos un estudio de coste-efectividad sobre su uso&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 171 biopsias de pulm&#243;n divididas en tres grupos&#58; grupo 1 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&#58; punci&#243;n aspirativa con aguja fina &#40;PAAF&#41; sin tap&#243;n de hidrogel&#59; grupo 2 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>89&#41;&#58; PAAF con tap&#243;n&#44; y grupo 3 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>60&#41;&#58; PAAF m&#225;s biopsia con aguja gruesa &#40;BAG&#41; con tap&#243;n&#46; Se calcularon costes totales &#40;directos e indirectos&#41; de los tres grupos&#46; Se analiz&#243; el porcentaje de diagn&#243;sticos correctos&#44; las ratios medias e incrementales y la opci&#243;n m&#225;s coste-efectiva&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Costes totales&#58; grupo 1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;261&#44;28<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>52&#44;65<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;313&#44;93 &#8364;&#44; grupo 2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;201&#44;36<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>67&#44;25<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;268&#44;61 &#8364;&#44; grupo 3<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;220&#44;22<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>47&#44;20<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;267&#44;42 &#8364;&#46; Porcentaje de diagn&#243;sticos correctos&#58; grupo 1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>77&#44;3&#37;&#44; grupo 2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>85&#44;4&#37; y grupo 3<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>95&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41;&#46; Ratio medio de coste-efectividad&#58; grupo 1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>16&#44;99&#44; grupo 2<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#44;85 y grupo 3<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#44;34&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El grupo 3 fue la opci&#243;n dominante&#44; con la menor ratio media&#44; lo cual demuestra que&#44; en las biopsias de pulm&#243;n guiadas por TC&#44; la opci&#243;n m&#225;s coste-efectiva es la realizaci&#243;n de una PAAF y una BAG con la utilizaci&#243;n del tap&#243;n de hidrogel deshidratado al final del procedimiento&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Marco-Dom&#233;nech SF&#44; Fern&#225;ndez-Garc&#237;a P&#44; Navarro-Ballester A&#44; Cifri&#225;n-P&#233;rez M&#44; Escobar-Valero &#193;&#44; Ib&#225;&#241;ez-Gual MV&#46; Estudio de coste-efectividad sobre la utilizaci&#243;n de un tap&#243;n de hidrogel en las biopsias pulmonares guiadas por tomograf&#237;a computarizada&#46; Radiolog&#237;a&#46; 2019&#59;61&#58;153&#8211;160&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Overall&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Groups 2 and 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Age &#40;<span class="elsevierStyleItalic">m</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#41;</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">68&#46;13<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;66</td><td class="td" title="table-entry  " align="left" valign="top">71&#46;18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">66&#46;85<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">68&#46;90<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&#46;68<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; group 2 &#8211; group 3&#41;&#58; 0&#46;244</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; groups 2 and 3&#41;&#58; 0&#46;238</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Pulmonary emphysema &#40;&#37;&#41;</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">25&#46;15&#37;</td><td class="td" title="table-entry  " align="left" valign="top">22&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; group 2 &#8211; group 3&#41;&#58; 0&#46;64</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; groups 2 and 3&#41;&#58; 0&#46;98</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Lesion diameter &#40;<span class="elsevierStyleItalic">m</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#41;</td><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">29&#46;95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;35</td><td class="td" title="table-entry  " align="left" valign="top">39&#46;64<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#46;17<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#46;98<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; group 2 &#8211; group 3&#41;&#58; 0&#46;0009</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value<br>Group 2 &#8211; group 1&#58; 0&#46;0007<br>Group 3 &#8211; group 1&#58; 0&#46;003<br>Group 3 &#8211; group 2&#58; 0&#46;923</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; groups 2 and 3&#41;&#58; 0&#46;004</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Skin-lesion distance &#40;<span class="elsevierStyleItalic">m</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#41;</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">65&#46;11<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;7</td><td class="td" title="table-entry  " align="left" valign="top">64&#46;95<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&#46;61<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#46;88<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">65&#46;14<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>22&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; group 2 &#8211; group 3&#41;&#58; 0&#46;946</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; groups 2 and 3&#41;&#58; 0&#46;975</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Pleura-lesion distance &#40;<span class="elsevierStyleItalic">m</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#41;</td><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">24&#46;22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;82</td><td class="td" title="table-entry  " align="left" valign="top">31&#46;45<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#46;42<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#46;40<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>16&#46;91&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#46;36<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>17&#46;21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; group 2 &#8211; group 3&#41;&#58; 0&#46;0332</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value<br>Group 2 &#8211; group 1&#58; 0&#46;31<br>Group 3 &#8211; group 1&#58; 0&#46;03<br>Group 3 &#8211; group 2&#58; 0&#46;20</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; groups 2 and 3&#41;&#58; 0&#46;09</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Patients&#8217; ages and characteristics of the biopsy lesions&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">m</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46;</p>"
          "tablatextoimagen" => array:4 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Pneumothorax &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Overall&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Group 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Group 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Group 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Groups 2 and 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">30&#46;99&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">54&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">29&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">25&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">27&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; group 2 &#8211; group 3&#41;&#58; 0&#46;03</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; group 3&#41;&#58; 0&#46;024<br><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; group 2&#41;&#58; 0&#46;046<br><span class="elsevierStyleItalic">p</span> value &#40;group 2 &#8211; group 3&#41;&#58; 0&#46;71</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; groups 2 and 3&#41;&#58; 0&#46;02</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1986220.png"
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            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Chest tube &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">7&#46;02&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">9&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">11&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">6&#46;7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; group 2 &#8211; group 3&#41;&#58; 0&#46;029</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; group 3&#41;&#58; 0&#46;07<br><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; group 2&#41;&#58; 1<br><span class="elsevierStyleItalic">p</span> value &#40;group 2 &#8211; group 3&#41;&#58; 0&#46;0059</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; groups 2 and 3&#41;&#58; 0&#46;65</td></tr></tbody></table>
                  """
              ]
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            2 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Length of hospital stay &#40;days&#41;<br>&#40;<span class="elsevierStyleItalic">m</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2&#46;46<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3&#46;41<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3&#46;26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2&#46;46<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2&#46;10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2&#46;32<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; group 2 &#8211; group 3&#41;&#58; 0&#46;005</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value<br><span class="elsevierStyleItalic">p</span> value &#40;group 2 &#8211; group 1&#41;&#58; 0&#46;033<br><span class="elsevierStyleItalic">p</span> value &#40;group 3 &#8211; group 1&#41;&#58; 0&#46;003<br><span class="elsevierStyleItalic">p</span> value &#40;group 3 &#8211; group 2&#41;&#58; 0&#46;359</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; groups 2 and 3&#41;&#58; 0&#46;003</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1986218.png"
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            3 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Correct diagnoses &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">87&#46;72&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">77&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">85&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">89&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; group 2 &#8211; group 3&#41;&#58; 0&#46;04<span class="elsevierStyleSup">a</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; group 3&#41;&#58; 0&#46;04<br><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; group 2&#41;&#58; 0&#46;55<br><span class="elsevierStyleItalic">p</span> value &#40;group 2 &#8211; group 3&#41;&#58; 0&#46;11</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">p</span> value &#40;group 1 &#8211; groups 2 and 3&#41;&#58; 0&#46;15<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td></tr></tbody></table>
                  """
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                0 => "xTab1986221.png"
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          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Fisher&#39;s exact test&#46;</p>"
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Complications&#44; length of hospital stay and percentage of correct diagnoses in the different biopsy groups&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Cyto&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>cytology&#59; histo&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>histology&#59; FNA&#58; fine needle aspiration&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Direct costs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Radiology Department</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">FNA<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;178&#46;48</td><td class="td" title="table-entry  " align="left" valign="top">FNA<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;178&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FNA<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;178&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Hydrogel<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;234&#46;74</td><td class="td" title="table-entry  " align="left" valign="top">Tru-cut needle<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;19&#46;96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hydrogel<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;234&#46;74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Anatomical Pathology Department</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Cyto&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;25&#46;13</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Cyto&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;25&#46;13</td><td class="td" title="table-entry  " align="left" valign="top">Cyto&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;25&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Histo&#46;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;110&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Length of stay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;41 days<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>&#8364;310&#46;17<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;1057&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;46 days<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>&#8364;310&#46;17<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;763&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;10 days<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>&#8364;310&#46;17<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;651&#46;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8364;1261&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8364;1201&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8364;1220&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Indirect costs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;41 days<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>&#8364;15&#46;44&#47;day<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;52&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;46 days<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>&#8364;27&#46;34&#47;day<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;67&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;10 days<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>&#8364;22&#46;48&#47;day<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8364;47&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total costs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8364;1313&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8364;1268&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8364;1267&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Costs for the different biopsy groups&#46;</p>"
        ]
      ]
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        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
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          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">&#916;Costs<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>cost increase with respect to the previous group&#59; &#916;Effects<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>effect increase with respect to the previous group&#59; ICER<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>incremental cost-effectiveness ratio&#59; ACER<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>average cost-effectiveness ratio&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="7" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Social perspective</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total costs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Effect&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ACER&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#916; Costs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#916; Effects&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ICER&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1267&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1267&#46;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1268&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;9&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1313&#46;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;8&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;5&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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            1 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="7" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Health service financier&#39;s perspective</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1201&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#46;86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;96&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&#46;45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;17&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;2&#46;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Summary table of the different groups&#8217; costs&#44; effects and cost-effectiveness analysis from the social perspective and the health service financier&#39;s perspective&#44; arranged from the lowest to highest cost&#46;</p>"
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Article information

ISSN: 21735107
Original language: English

DOI:10.1016/j.rxeng.2019.01.007

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Year/Month	Html	Pdf	Total

2024 October	2	2	4
2024 September	0	1	1
2024 August	2	1	3
2024 January	3	1	4
2023 December	1	0	1
2023 September	1	0	1
2023 April	5	5	10
2023 March	2	1	3
2023 January	1	2	3
2022 December	1	2	3
2021 January	1	0	1
2020 July	4	2	6
2020 April	2	2	4
2020 March	1	0	1
2019 November	4	2	6
2019 July	1	0	1
2019 May	2	2	4
2019 April	1	0	1
2019 March	5	4	9

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