Peritonectomy and hyperthermic intraperitoneal chemotherapy: cost analysis and sustainability.

BACKGROUND: Malignancies of the peritoneum remain a challenge in any hospital that accepts to manage them, due not only to difficulties associated with the complexity of the procedures involved but also the costs, which - in Italy and other countries that use a diagnosis-related group (DRG) system - are not adequately reimbursed. MATERIAL AND METHODS: We analyzed data relative to 24 patients operated on between September 2010 and May 2013 with special regard to operating room expenditure, ICU stay, duration of hospitalization, and DRG reimbursement. The total costs per patient included clinical, operating room, procedure, pathology, imaging, ward care, allied healthcare, pharmaceutical, and ICU costs. RESULTS: Postoperative hospital stay, drugs and materials, and operating room occupancy were the main factors affecting the expenditure for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. We had a median hospitalization of 14 days, median ICU stay of 2.4 days, and median operating room occupancy of 585 min. The median expenditure for each case was € 21,744; the median reimbursement by the national health system € 8,375. CONCLUSIONS: In a DRG reimbursement system, the economic effort in the management of patients undergoing peritonectomy procedures may not be counterbalanced by adequate reimbursement. Joint efforts between medical and administration parties are mandatory to develop appropriate treatment protocols and keep down the costs.

Platypnea-orthodeoxia syndrome in interatrial right to left shunt postpneumonectomy.

Platypnea-orthodeoxia is a syndrome characterized by dyspnea and hypoxemia on adoption of an upright posture (i.e., orthodeoxia), and by the absence or reduction of symptoms and of hypoxemia in a supine position. We describe the case of a 64-year-old patient who had developed an acute respiratory insufficiency due to right-to-left shunt in a patent foramen ovale one month after right intrapericardiac pneumonectomy. The patient was initially treated unsuccessfully with bronchodilators, corticosteroids and oxygen therapy. He was then admitted to the ICU due to severe refractory hypoxemia. Diagnosis of platypnea-orthodeoxia syndrome was demonstrated by O2 saturation and arterial blood gas analysis in the supine and upright positions. The presence of a right-to-left interatrial shunt through a patent foramen ovale was documented by transesophageal echocardiography 24 h after admission to intensive care. The next day, the patient underwent a percutaneous occlusion procedure with an Amplatzer device after consultation with surgeons and cardiologists. The patient was dismissed from the ICU after 24 hours of monitoring, and successfully discharged to home after one week.

Plasmodium vivax congenital malaria in a newborn of a Zairian immigrant.

We report a case of congenital malaria in a newborn whose mother is a native of Zaire now living in Italy. The baby developed remittent fever in the 3rd week of life with anaemia and hepatosplenomegaly. Malaria parasites found in blood smears and erroneously diagnosed initially as Plasmodium falciparum were subsequently recognized as Plasmodium vivax. On the basis of the first diagnosis, treatment with quinine chlorhydrate was successfully undertaken without significant side-effects. P. vivax parasites were also recovered a posteriori in blood smears of the mother who was febrile during the week of her delivery. This report suggests that symptomatic congenital malaria may be more common than is generally thought and should be suspected in non-malarious countries in febrile newborns born to mothers who have travelled in or immigrated from malaria-endemic areas.

Efficacy and safety of permanent cardiac DDD pacing with contemporaneous double spinal cord stimulation.

Spinal cord stimulation (SCS) is currently used to treat peripheral vascular disease (PVD) and refractory angina pectoris not amenable to revascularization. In a case of contemporaneous SCS implant and permanent cardiac pacemaker (PPM), if multipolar electrodes are used it is possible to avoid any interference between the systems. We describe the case of a patient with a DDD pacemaker, in whom two bipolar SCSs were implanted at different times: one to control refractory angina pectoris and the other for PVD. No interference between the three systems has been observed.

[Epidural electrostimulation in the treatment of refractory angina pectoris in elderly patients: preliminary results]. / L'elettrostimolazione epidurale nel trattamento dell'angina pectoris refrattaria nel paziente anziano: esperienza preliminare.

The spinal cord stimulation is an antalgic technique which has been used since 1967 for the treatment of several painful syndromes. More recently it was employed in the cardiology field to treat refractory angina, not suitable for revascularization. We applied spinal cord stimulation as alternative therapy in 7 clients older than 70 years who, for different reasons, could not undergo revascularization. We obtained good short- and long-term clinical results, without complications. On the basis of our preliminary experience with this technique in a small group of elderly patients and after a critical review of the literature, we conclude that spinal cord stimulation can be used without significant risks, in elderly patients with refractory angina pectoris.