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patients aged 0.5 to 20 years received a bidirectional Glenn shunt without the use of a temporary shunt or cardiopulmonary bypass. Arterial oxygen saturation rose from 78% ± 8.5% preoperatively to 90% ± 4.3% postoperatively. Hemodynamic studies showed a mean postoperative superior vena cava pressure of 13 ± 2 mm H 2 O. One patient had desaturation and the shunt was taken down, 5 required reexploration for bleeding, and 8 needed prolonged drainage of 9 to 19 days, 2 of whom had chylothorax. Hospital stay was 9.3 ± 3.5 days. There were 3 late operative deaths (1.8%) from low output syndrome. In 20 patients, bilateral bidirectional Glenn shunts were instituted. Three patients underwent a subsequent Fontan procedure without cardiopulmonary bypass. The bidirectional Glenn shunt remains an excellent palliative procedure as a preliminary step to a Fontan operation, or as an integral part of a Fontan or modified Fontan operation when the procedure is deferred because of age, weight, or cardiac malformations characterized by a hypoplastic right or left ventricle.

Background Multiple modern Indian hospitals operate at very low cost while meeting US-equivalent quality accreditation standards. Though US hospitals face intensifying pressure to lower their cost, including proposals to extend Medicare payment rates to all admissions, the transferability of Indian hospitals' cost advantages to US peers remains unclear.Methods Using time-driven activity-based costing methods, we estimate the average cost of personnel and space for an elective coronary artery bypass graft (CABG) surgery at two American hospitals and one Indian hospital (NH). All three hospitals are Joint Commission accredited and have reputations for use of modern performance management methods. Our case study applies several analytic steps to distinguish transferable from non-transferable sources of NH's cost savings.Results After removing non-transferable sources of efficiency, NH's residual cost advantage primarily rests on shifting tasks to less-credentialed and/or less-experienced personnel who are supervised by highly-skilled personnel when perceived risk of complications is low. NH's high annual CABG volume facilitates such supervised work "downshifting." The study is subject to limitations inherent in case studies, does not account for the younger age of NH's patients, or capture savings attributable to NH's negligible frequency of re-admission or post-acute care facility placement.Conclusions Most transferable bases for a modern Indian hospital's cost advantage would require more flexible American states' hospital and health professional licensing regulations, greater family participation in inpatient care, and stronger support by hospital executives and clinicians for substantially lowering the cost of care via regionalization of complex surgeries and weekend use of costly operating rooms.

We have used a telemedicine facility to conduct academic teaching/training sessions. The objective of this study was to examine the feasibility, advantages, and disadvantages of this method of e-learning sessions. The teaching/learning sessions were organized twice a week between the two teaching hospitals. The success of each academic session was analyzed in terms of satisfaction of the participating candidates, infrastructure difficulties (if any), and the overall outcome of the program. In total, 293 academic sessions were held from 2008 to 2010. Each session's presentation was 45 min long and was made using Microsoft(®) (Redmond, WA) PowerPoint. We have found that telemedicine proved to be effective in establishing communication not only between the patient and the physician, but also between the teacher and the student. Several candidates benefited from the application of this technology. Candidates expressed satisfaction and were content with the teaching methods adapted.