Endovascular technology can be helpful in treating selected young patients with genetically triggered thoracic aortic disease. Long-term studies and further evolution of endovascular technology will be necessary for it to be incorporated into the armamentarium of surgical options for this challenging patient population.
Objectives Thoracic outlet syndrome, a condition commonly reported in adults, occurs infrequently in the pediatric population. The objective of this study was to assess the outcome of surgical interventions of thoracic outlet syndrome in pediatric patients. Methods Clinical records of all pediatric patients with thoracic outlet syndrome who underwent operative repair from 2002 to 2015 in a tertiary pediatric hospital were reviewed. Pertinent clinical variables and treatment outcomes were analyzed. Results Sixty-eight patients underwent a total of 72 thoracic outlet syndrome operations (mean age 15.7 years). Venous, neurogenic, and arterial thoracic outlet syndromes occurred in 39 (57%), 21 (31%), and 8 (12%) patients, respectively. Common risk factors for children with venous thoracic outlet syndrome included sports-related injuries (40%) and hypercoagulable disorders (33%). Thirty-five patients (90%) with venous thoracic outlet syndrome underwent catheter-based interventions followed by surgical decompression. All patients underwent first rib resection with scalenectomy via either a supraclavicular approach (n = 60, 88%) or combined supraclavicular and infraclavicular incisions (n = 8, 12%). Concomitant temporary arteriovenous fistula creation was performed in 14 patients (36%). Three patients with arterial thoracic outlet syndrome underwent first rib resection with concomitant subclavian artery aneurysm repair. The mean follow-up duration was 38.4 ± 11.6 months. Long-term symptomatic relief was achieved in 94% of patients. Conclusions Venous thoracic outlet syndrome is the most common form of thoracic outlet syndrome in children, followed by neurogenic and arterial thoracic outlet syndromes. Competitive sports-related injuries remain the most common risk factor for venous and neurogenic thoracic outlet syndromes. Temporary arteriovenous fistula creation was useful in venous thoracic outlet syndrome patients in selective children. Surgical decompression provides durable treatment success in children with all subtypes of thoracic outlet syndrome.
Objectives: To estimate the cost-effectiveness of nab-paclitaxel+gemcitabine (Npg) versus gemcitabine (Gem) alone for the first-line treatment of metastatic pancreatic cancer in Greece from a National Health System perspective MethOds: A Markov model was developed, included several stages such as: "pre-progression on firstline treatment", "pre-progression off first-line treatment", "post progression", "four weeks to death" and "death". Data from the MPACT trial were used to estimate overall survival (Life-Years-(LYs)) and adverse events. The prices of drugs used in the model are publicly available for all hospitals in Greece. Cost assigned in each health state reflected: drugs, adverse events, monitoring, administration and palliative care. Utility values were obtained from the international literature to estimate Quality-Adjusted-Life-Years (QALYs). Costs and health gains were discounted at 3.5% per annum. A probabilistic sensitivity analysis was also conducted to construct confidence intervals (CI). Results: The mean number of QALYs was 0.71 (95%CI: 0.66-0.78) and 0.56 (95%CI: 0.52-0.60) for Npg and Gem, respectively, giving an incremental gain of 0.15 (95%CI: 0.08-0.25) QALYs in favour of Npg. The mean cost of therapy per patient was estimated at € 15,628 (95%CI: € 14,377-€ 17,027) and € 8,284 (95%CI: € 7,455-€ 9,112) for Npg and Gem, respectively. The incremental cost per LY gained with Npg was estimated at € 37,007 and the incremental cost per QALY gained at € 47,120. The probability for Npg to be cost-effective at a threshold three times the per capita income (€ 60,000 per QALY) was 82%. cOnclusiOns: The severity of pancreatic cancer, in combination with the limited number of effective treatments, results in a high level of unmet need. If the societal willingness-to-pay threshold for an additional QALY is relatively higher for patients with short life expectancy or for diseases with a relatively higher burden, the combination of nab-paclitaxel+gemcitabine could be considered a cost-effective choice compared with gemcitabine alone in Greece.
Background: vitamin D deficiency is very common, and has been demonstrated in multiple studies in both the general population and in patients with different pathologies. However, it has been little studied in patients affected by spinal injury. Objective: to study the prevalence of hypovitaminosis D and the possible development of secondary hyperparathyroidism in a population of patients with spinal injury. Material and method: transverse descriptive study carried out in 104 patients affected by spinal injury. A clinical history was taken, a detailed physical examination carried out and a blood sample while fasting taken, with the least possible compression, from all patients. The analytical parameters were analysed using automated techniques and the determination of 25-hydroxyvitamin D (25HCC) and parathyroid hormone (PTH) was performed using electroimmunochemiluminescence (ECLIA). Results: the global mean value of 25-hydroxyvitamin D was 20.1 ± 11.6 n/ml. 84.6% of the patients had blood values of 25-hydroxyvitamin D lower than 30 ng/ml and 62% of all patients showed values lower than 20 ng/ml. The prevalence of vitamin D deficiency was similar in men and women. However, although we found an inverse correlation between levels of PTH and hydroxyvitamin D, only 5.8% of patients ended up developing secondary hyperparathyroidism. Conclusions: there is a high prevalence of hypovitaminosis D in patients with spinal injury. It is advisable, therefore, to include a study of this metabolite in the care protocol of these patients to correct these deficiencies as and when they are found.
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