Left ventricular volume reduction surgery in the middle East

Heart transplantation is not yet socially acceptable in the Middle East, and left ventricular assist facilities are not generally available in this region. Therefore, left ventricular volume reduction surgery was attempted in 41 patients with end-stage heart failure (33 males; median age, 36.3 years) in 4 Middle Eastern tertiary referral centers between February 1996 and January 2001. Heart failure was due to idiopathic cardiomyopathy in 21 patients, ischemia in 11, rheumatic valvular disease in 8, and viral myocarditis in 1. Associated procedures were aortic valve replacement in 5 patients, mitral valve repair in 25, mitral valve replacement in 7, tricuspid valve repair in 6, and coronary bypass grafting in 8. Hospital mortality was 31.7%. Five patients were lost to follow-up. The survival rate of hospital survivors at 18 months was 65.2%. Three of the surviving patients did not benefit from the operation. Although our results were somewhat disappointing, this operation remains an option for surgeons working in developing areas of the world. It is hoped that better patient selection and new techniques of left ventricular volume reduction that avoid resection of viable muscle will further improve the outcome of this operation.     

Place of Video-thoracoscopy in Thoracic Surgical Practice

The advent of video-endoscopy revolutionizes the practice of surgery. Within a short span of time, video-assisted thoracic surgery (VATS) has become an acceptable approach to a wide range of thoracic procedures. The use of VATS as a diagnostic modality is now well established. For therapeutic procedures, VATS has also been generally accepted for the treatment of such conditions as primary spontaneous pneumothorax, loculated effusions, thoracodorsal sympathectomy, and resection of simple mediastinal cysts. Its roles in more complex procedures such as thymectomy and anatomic lung resections, however, remain poorly defined at present, even though the existing intermediate-term results are encouraging. VATS is still in evolution. Miniaturization of instruments promises to reduce access-induced trauma even further. On the other hand, attention to cost-containment is essential if VATS is to be applicable to patients in developing countries. Technology will continue to change. Carefully conducted clinical trials should precede the general acceptance of any new technology, no matter how attractive it may appear initially.     

Video-assisted thoracic surgery: A renaissance in surgical therapy

Within a few years, video-assisted thoracic surgery (VATS) has become the accepted or preferred approach over a wide range of thoracic procedures. The authors review the development of this technique, the basic operative strategies and the current surgical indications. Technical pitfalls and future developments are also discussed.     

左心室部分切除术治疗终末期心力衰竭

目的　对终末期扩张型心肌病患者采用外科左心室部分切除术减小左心室容积 ,并观察缓解心力衰竭 (心衰 )的疗效。方法　 4例患有进行性加重的充血性心衰患者的病因分别为原发性(2例 )、瓣膜性(1例 )和缺血性 (1例 )心肌病 ,所采用的术式包括“乳头肌间室壁切除”1例及“超乳头肌室壁切除”3例 (后者含二尖瓣替换)。同期手术还包括主动脉瓣替换 2例和冠状动脉搭桥 1例。结果　所有患者都顺利脱离体外循环 ,并在术后 (2 5± 2 )小时拔除气管插管。心输出量由术前 (2 0±0 2 )升 /min增至术后 (4 1±0 3 )升 /min(P =0 .0 0 1)。除 1例患者 3周后死于细菌性纵隔感染所致败血症外 ,另 3例平均 14天后出院。随访 (最多达 2 2个月 )证实这 3例患者均保持在纽约心脏协会心功能Ⅰ级。结论　左心室部分切除术为终末期扩张型心肌病患者缓解心衰症状 ,早期临床效果良好。     

Comparable Rates of Glucocorticoid‐Associated Adverse Events in Patients With Polymyalgia Rheumatica and Comorbidities in the General Population

Objective

To investigate the use of glucocorticoids (GCs) and related adverse events (AEs) in a long‐term, geographically defined cohort of patients with polymyalgia rheumatica (PMR).

Methods

Using a population‐based inception cohort, details of GC therapy were abstracted from medical records of all patients diagnosed with PMR in 2000–2014. Age‐ and sex‐matched comparators without PMR were identified from the same underlying population. Cumulative and daily dosage of GC, rate of disease relapse, occurrence of GC‐related AEs, and rate of GC discontinuation were analyzed.

Results

The study included 359 patients with PMR and 359 comparators. The median time to taper below 5 mg/day for 6 months was 1.44 years (95% confidence interval [95% CI] 1.36–1.62), while the median time to permanent discontinuation was 5.95 years (95% CI 3.37–8.88). The mean ± SD cumulative dose of GC at 2 and 5 years was 4.0 ± 3.5 grams and 6.3 ± 9.8 grams, respectively. The mean ± SD daily dose of GC at 2 and 5 years was 6.1 ± 7.6 mg/day and 7.2 ± 9.5 mg/day, respectively. There were no differences in rates of AEs between patients with PMR and comparators for diabetes mellitus, hypertension, hyperlipidemia, or hip, vertebral, or Colles fractures (P > 0.2 for all). Cataracts were more common in patients with PMR than comparators (hazard ratio 1.72 [95% CI 1.23–2.41]).

Conclusion

Relapse rates in PMR are highest in the early stages of therapy. Despite often protracted therapy, with the exception of cataracts, the rates of studied morbidities linked to GC are not more common in PMR than comparators.

     

Video-assisted interventional bronchoscopy

Background: Major airway obstruction due to benign or malignant etiology is not uncommon and is always distressing. Intraluminal stenting has been shown to be a safe and effective approach for symptomatic relief in selected patients based on the European and North American experience. Methods: We reviewed our experience in Hong Kong on airway stenting over a 19-month period. Results: From February 1994 to August 1995, 33 silicone stents (Dumon stent, Cometh, Marseille, France) were placed in 23 patients (20 males, three females with mean age 61.4 years, range from 26 to 81). Eighteen stents were placed in the trachea, nine in the left main stem, five in the right main stem, and one Y-stent over the carina. Twelve patients had esophageal carcinoma involving the airway, seven had bronchial carcinoma, one had metastatic carcinoma, and three had benign strictures (of which two were due to tuberculosis). There was no procedural related mortality. Stent migration occurred in four patients (17%) and required stent change. Symptoms were improved in all patients as documented by the visual analogue scale. Conclusion: Our experience represents the ``stentable' diseases seen in Hong Kong, where carcinoma of the esophagus (and tuberculosis) remains prevalent. We conclude that intraluminal stenting remains a safe and effective approach in selected patients with critical airway stenosis. Complications, however, do exist and should be realized by the operator, the patients, and their families. Received: 4 September 1996/Accepted: 3 August 1996