Partial anomalous pulmonary venous return: Scimitar vein.

Scimitar syndrome is a rare association of congenital cardiopulmonary anomalies characterized by partial anomalous pulmonary venous return, in which an abnormal right pulmonary vein drains into the inferior vena cava. This case exemplifies the role of transesophageal echocardiography in perioperative management and surgical decision-making.

The efficacy of automated intermittent boluses for continuous femoral nerve block: a prospective, randomized comparison to continuous infusions.

STUDY OBJECTIVE: To determine whether an automated intermittent bolus technique provides enhanced analgesia compared with a continuous infusion for femoral nerve block. DESIGN: Prospective, single-blinded, randomized controlled trial (ClinicalTrials.gov Identifier: NCT01226927). SETTING: Perioperative areas and orthopedic surgical ward of a university hospital. PATIENTS: 45 ASA physical status 1, 2, and 3 patients undergoing unilateral primary total knee arthroplasty. INTERVENTIONS: All patients received single-injection sciatic and femoral nerve blocks plus femoral nerve catheter placement for postoperative analgesia. Patients were randomly assigned to an automated intermittent bolus (5 mL every 30 min with 0.1 mL/hr basal rate) or a continuous infusion (10.1 mL/hr) delivery method of 0.2% ropivacaine. MEASUREMENTS: Consumption of intravenous patient-controlled analgesia (IV-PCA) and visual analog scale (VAS) pain scores were assessed postoperatively at set intervals until the morning of postoperative day (POD) 2. MAIN RESULTS: The mean (SEM) cumulative IV-PCA dose (mg of hydromorphone) for the 36-hour postoperative interval measured was 12.9 ± 2.32 in the continuous infusion rate group (n = 20) and 7.8 ± 1.02 in the intermittent bolus group [n = 21, t(39) = 2.04, P = 0.048; a 39 ± 14% difference in total usage]. Pain scores were statistically significantly lower in the intermittent bolus group in the afternoon of POD 1 (t(39) = 2.47, P = 0.018), but were otherwise similar. CONCLUSIONS: An automated intermittent bolus infusion technique for femoral nerve catheters is associated with clinically and statistically significantly less IV-PCA use (ie, an opioid-sparing effect) than a continuous infusion technique.

PEPFAR's past and future efforts to cut costs, improve efficiency, and increase the impact of global HIV programs.

Amid the global economic crisis, the President's Emergency Plan for AIDS Relief (PEPFAR) and other organizations have been pressed to do more with constrained resources to meet unmet needs in the worldwide HIV/AIDS pandemic. PEPFAR has approached this challenge through the development of an Impact and Efficiency Acceleration Plan, which includes improving the collection and use of economic and financial data, increasing the efficiency of HIV/AIDS program implementation, and collaborating with governments and multilateral organizations to maximize the impact of the resources provided by the United States. For example, by linking financial data with program outputs, PEPFAR was able to help its implementing partners in Mozambique reduce mean unit expenditures for people receiving antiretroviral treatment by 45 percent, from $265 to $145 per person, between 2009 and 2011. This article describes the plan's elements, provides examples of progress and challenges to its implementation, and assesses the prospects for further improvements in efficiency and impact.

Modeling the impact of HIV chemoprophylaxis strategies among men who have sex with men in the United States: HIV infections prevented and cost-effectiveness.

BACKGROUND AND OBJECTIVE: HIV chemoprophylaxis may be a future prevention strategy to help control the global epidemic of HIV/AIDS. Safety and efficacy trials of two agents are currently underway. We assess the expected number of HIV cases prevented and cost-effectiveness of a hypothetical HIV chemoprophylaxis program among men who have sex with men in a large US city. DESIGN AND METHODS: We developed a stochastic compartmental mathematical model using HIV/AIDS surveillance data to simulate the HIV epidemic and the impact of a 5-year chemoprophylaxis program under varying assumptions for epidemiological, behavioral, programmatic and cost parameters. We estimated program effectiveness and costs from the perspective of the US healthcare system compared with current HIV prevention practices. The main outcome measures were number of HIV infections prevented and incremental cost per quality-adjusted life-years saved. RESULTS: A chemoprophylaxis program targeting 25% of high-risk men who have sex with men in New York City could prevent 780 (4%) to 4510 (23%) of the 19 510 HIV infections predicted to occur among all men who have sex with men in New York City in 5 years. More than half of prevented infections would be among those not taking chemoprophylaxis but who benefit from reduced HIV prevalence in the community. Under base-case assumptions, incremental cost was US$ 31 970 per quality-adjusted life-years saved. The program was cost-effective under most variations in efficacy, mechanism of protection and adherence. CONCLUSION: HIV chemoprophylaxis among high-risk men who have sex with men in a major US city could prevent a significant number of HIV infections and be cost-effective.

The cost-effectiveness of treating male trichomoniasis to avert HIV transmission in men seeking sexually transmitted disease care in Malawi.

OBJECTIVE: Allocation of funds to program areas where they may have an impact is critical to the success of any HIV control program. We examined the cost-effectiveness of providing first-line treatment for male trichomoniasis in Malawi, a condition not commonly considered in syndromic management throughout sub-Saharan Africa. METHODS: We used decision tree analysis to assess program costs and outcomes among a 1-year population of male sexually transmitted disease (STD) clinic attendees estimated at 10,000 in Lilongwe. Our main outcomes were program costs from the government perspective and HIV infections averted. We conducted univariate and multivariate sensitivity analyses on selected parameters. RESULTS: In our study population of male STD clinic attendees with an HIV prevalence of 44% and a Trichomonas vaginalis prevalence of 20%, including universal metronidazole as a first-line treatment for trichomoniasis at $0.05 per dose would increase program costs by $277 (year 2000 US dollars) and avert 23 cases of HIV. The incremental cost-effectiveness ratio (ICER) over the current STD management guidelines was $15.42 per case of HIV averted. The number of HIV infections averted under sensitivity analysis ranged from 2 to 52, with attendant ICERs varying from cost savings to $162.92. Consideration of wider social benefits, such as the costs of HIV infections to the individual or the government, would further enhance the cost-effectiveness of this program. CONCLUSIONS: As part of a larger program to control STDs, incorporating metronidazole to treat male trichomoniasis could represent a cost-effective means to reduce HIV transmission in this high-risk group.

Anatomic and hemodynamic imaging using a new vector phased-array intracardiac catheter.

BACKGROUND: We used a new vector, phased-array intracardiac catheter (AcuNav) with complete 2-dimensional imaging and Doppler capabilities to describe a systematic approach for a detailed anatomic and hemodynamic cardiac assessment. METHODS: In 14 dogs, the intracardiac echocardiographic catheter was inserted through an 11F venous access and placed in the right side of the heart to perform a comprehensive ultrasound examination of the heart. RESULTS: Imaging was successful in all dogs. All 4 cardiac chambers and valves were imaged clearly in multiple orientations. Additional structures seen included the vena cavae, coronary sinus, right and left appendages, interarterial septum, coronary arteries, and all 4 pulmonary veins. Intra-abdominal structures, such as the aorta, liver, and hepatic veins were also visualized. A complete Doppler examination of intracardiac and paracardiac flows was also possible. CONCLUSION: AcuNav is a unique intracardiac imaging device, which allows comprehensive structural and functional cardiac assessment.

Catheter-based interventions guided solely by a new phased-array intracardiac imaging catheter: in vivo experimental studies.

BACKGROUND: Intracardiac echocardiography (ICE) has had useful but limited use during interventional procedures because of technologic limitations. We used a novel phased-array ICE device (AcuNav) with 2-dimensional sector imaging and full Doppler capability to see whether it could guide cardiac interventions without fluoroscopy. METHODS: Twelve dogs were studied, and we performed atrial septostomy, tricuspid, and pulmonary valve disruption using only ICE. Preinterventional and postinterventional anatomic and hemodynamic data were noted. RESULTS: All attempts were successful in the placement of the ICE catheter (100%). We attempted septostomy on 11 dogs and were successful 8 times (73%). Tricuspid valve disruption and balloon dilatation were performed successfully on 5 dogs (100%). We attempted pulmonary valve disruption on 4 dogs and could always correctly place the guidewire (100%). We performed pulmonary valve balloon dilatation on one dog (25%). A comprehensive echocardiographic examination was always possible. CONCLUSION: This new ICE device can guide interventions without fluoroscopy. However, further studies are needed to evaluate whether it can replace fluoroscopy.