Successful thoracoscopic excision of complex supracardiac middle mediastinal bronchogenic cyst in an infant.

Introduction: We report the first case of complex supracardiac middle mediastinal foregut duplication lesion compressing and adherent to the heart, managed successfully thoracoscopically in an infant, in an innovative way. Materials and Surgical Technique: A 1-year-old girl was diagnosed as having supracardiac middle mediastinal foregut duplication lesion. It was completely overlying and adherent to her heart giving transmitted pulsations to the lesion, causing indentation over the left atrium and surrounded by all vital structures such as aorta, pulmonary artery, bronchi and phrenic nerve. After proper counselling of parents and relatives, the patient was posted for surgery. After proper positioning, thoracoscopic access was gained, difficulty here was neither bulge nor surface marking of the lesion was seen in thoracic cavity anywhere, considering the anatomical relations. The mediastinal pleura was opened, through a very narrow window for accessing the lesion, which was surrounded by vital structures in the middle mediastinum. A gentle dissection of the lesion was done to relieve it from adjacent adhered thoracic vitals structures successfully. Histopathological examination confirmed it as a bronchogenic cyst. Discussion: Foregut duplication cyst, especially bronchogenic cysts, have been reported at various locations, however, supracardiac middle mediastinal bronchogenic cyst completely sitting on the heart, adherent to it causing compression of the left atrium and left bronchus and surrounded completely by the aorta, pulmonary artery and bronchus, has not been reported till date. Also, successful thoracoscopic excision of such rarely located lesion moving with heart, in a 1-year-old girl, has not been reported yet.

Evaluating efficiency-equality tradeoffs for mobile source control strategies in an urban area.

In environmental risk management, there are often interests in maximizing public health benefits (efficiency) and addressing inequality in the distribution of health outcomes. However, both dimensions are not generally considered within a single analytical framework. In this study, we estimate both total population health benefits and changes in quantitative indicators of health inequality for a number of alternative spatial distributions of diesel particulate filter retrofits across half of an urban bus fleet in Boston, Massachusetts. We focus on the impact of emissions controls on primary fine particulate matter (PM(2.5)) emissions, modeling the effect on PM(2.5) concentrations and premature mortality. Given spatial heterogeneity in baseline mortality rates, we apply the Atkinson index and other inequality indicators to quantify changes in the distribution of mortality risk. Across the different spatial distributions of control strategies, the public health benefits varied by more than a factor of two, related to factors such as mileage driven per day, population density near roadways, and baseline mortality rates in exposed populations. Changes in health inequality indicators varied across control strategies, with the subset of optimal strategies considering both efficiency and equality generally robust across different parametric assumptions and inequality indicators. Our analysis demonstrates the viability of formal analytical approaches to jointly address both efficiency and equality in risk assessment, providing a tool for decisionmakers who wish to consider both issues.