The Warden procedure has been described for the repair of a partial anomalous pulmonary venous connection that is inserted high in the superior vena cava. One long-term concern remains, which is related to the narrowing of the superior vena caval anastomosis. In fully grown teenagers and adults, we have modified the procedure by using an interposition graft that consists of a descending thoracic aortic homograft. It usually matches the size of the superior vena cava and avoids the need for anticoagulation. We also insert the homograft into the free wall of the right atrium rather than into the atrial appendage. We present the technique in a 16-year-old girl through a vertical right axillary thoracotomy.
Abstract Background Pneumatosis intestinalis has long been a marker of advanced bowel ischemia and prompts urgent laparotomy. In post-operative settings, the presence of pneumatosis represents a significant management dilemma. We share a case-series of post-esophagectomy patients with pneumatosis intestinalis and no corollary intra-abdominal pathologic findings on re-exploration. Methods January 2000 to December 2017, 1760 patients underwent Ivor-Lewis esophagectomy or gastrectomy with jejunostomy-tube placement. Charts were reviewed retrospectively to identify patients with pneumatosis intestinalis discovered in the post-operative period. Demographic data, operative details and postoperative course were reviewed including incidence and details of re-exploration. Results Eleven patients met inclusion criteria. Nine were male (81.8%) and mean age was 69 years. All patients had radiographic confirmation of pneumatosis intestinalis and in many cases portal venous gas (Figure 1). Clinical course was variable without discernable trends in vitals or laboratory values. Development of significant postoperative ileus along with delivery of enteral tube feeds through a jejunostomy tube preceded development of the pneumatosis in all patients. Nine patients were re-explored and none had evidence of bowel ischemia. Conclusion The finding of pneumatosis intestinalis in the post-operative setting can be alarming and pose a management dilemma. With the advent of improved and readily available imaging, there has been an increase in findings that have no corollary physical symptomatology. In this series of patients, despite dramatic radiographic findings, none had ischemic bowel. Pneumatosis intestinalis alone in patients who have undergone esophagectomy should not be considered an indication for emergency re-exploration. Disclosure All authors have declared no conflicts of interest.
Rheumatoid arthritis (RA) is a major global health problem and a neglected disease in many developing countries. Health care spending is low in these countries and RA services compete with other important life-saving and effective interventions. Effective therapies for RA are now available which improve overall outcomes and prevent disability especially when initiated early and managed aggressively [1]. All these interventions are available in high-income countries but are sparse in developing countries. There are several health economic evaluations of RA treatment from high-income settings, but few are available or relevant for developing countries. More evidence is therefore needed on the benefits and costs of scaling-up RA services in resource constrained settings.
Objectives
To conduct a cost effectiveness analysis of multiple interventions in the management of RA in Zanzibar.
Methods
A cost-effectiveness analysis for a ten-year duration was conducted from a health provider perspective using a Markov model. Interventions were based on a treat to target strategy with add on therapy or switch to biologic therapy when patients did not reach target (remission or low disease activity). The model compares the efficiency of 'methotrexate monotherapy'(option1), 'methotrexate + sulfasalazine + hydroxychloroquine (triple therapy)' (option 2), methotrexate then biologic 1' (option 2b), 'option 2 then biologic 1' (option 3), 'option 3 then biologic 2' (option 4) and 'option 2b then biologic 2' (option 4b). Data on effectiveness of interventions was obtained from literature. Incremental cost-effectiveness ratios (ICERS) were calculated per quality adjusted life year (QALY) gained from treatment. Staff, building, and utility costs were obtained from the hospital administration records. Drug costs were obtained from the government supplier price list, retail pharmacies and pharmaceutical companies. Mean utility values were calculated from a Zanzibar RA- cohort based on the EuroQol-5D questionnaire responses. Willingness to pay threshold (WTP) was set at 568 USD which is two-thirds of GDP/capita for Tanzania for 2021. We conducted a base case analysis with deterministic sensitivity analysis to explore outcomes with changes in key parameters.
Results
Total costs for the treatment options were largely driven by drugs, predominantly the biologics. The lowest cost was for methotrexate therapy (option 1) at USD 1984/patient/10 years and the highest utilities were gained from treatment with methotrexate therapy + two consecutive bDMARDs (option 4b) (Table 1). Changes in drug costs resulted in significant changes in the ICERs. With variations in the WTP threshold, option 1 remained the most CE to just above USD 2500 where option 2b became the more CE option up to USD 3100 and option 3 became the more CE option. All other options were not considered CE up to 3500 USD.
Conclusion
Methotrexate was found to be the only cost-effective treatment option in our population. Other options although available may be too costly to consider feasible for clinical use unless prices drop. This may be possible via wider availability of biosimilars or via government drug price negotiation to acquire drugs at cheaper costs.
Reference
[1] Smolen JS, Breedveld FC, Burmester GR, Bykerk V, Dougados M, Emery P, et al. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Ann Rheum Dis. 2016 Jan;75(1):3–15.
Raghib defect and double-orifice tricuspid valve are two rare congenital heart defects. We report a case of a 42-year-old man with both Raghib defect and DOTV. The patient underwent reroofing of the coronary sinus with an intra-atrial baffle and annuloplasty of the tricuspid and mitral valves via median sternotomy.
BACKGROUNDCardiovascular disease is the leading cause of death in patients with Turner syndrome (TS), and cardiovascular surgery is frequently required for management of these patients.TS is associated with medical comorbidities than can complicate the care of this patient population. AIMTo describe the cardiovascular surgical outcomes of patients with TS. METHODSA retrospective case series was compiled of 51 consecutive TS patients who had at least one cardiovascular surgery at Mayo Clinic Rochester from 1977-2017.The baseline clinical data of these patients were reviewed including demographics, medical comorbidities, congenital heart disease history, and medications.Echocardiographic reports were analyzed in detail.Operative reports and surgical hospital courses were reviewed.Long-term mortality was determined using medical records and the Social Security Death Index.Survival analysis was performed with the Kaplan Meier method. RESULTSThe cohort comprised 51 TS patients, average age at the time of surgery at Mayo Clinic was 28 (8-41) years, and 23 (45%) patients were under the age of 18.At the WJC https://www.wjgnet.com
Partial anomalous pulmonary venous return (PAPVR) is a rare congenital condition, and dual-drainage connection PAPVR to the left atrium has been reported in a few cases in the literature; in which cases, percutaneous catheterization was successfully used in lieu of surgery. We, hereby, describe a 7-month-old boy with a functional single-ventricle physiology with dual drainage of the left upper pulmonary vein to the left atrium and the innominate vein. Appropriate recognition of this entity allowed safe occlusion of the anomalous draining vein.
