Machine learning, deep learning and hernia surgery. Are we pushing the limits of abdominal core health? A qualitative systematic review

INTRODUCTION

This systematic review aims to evaluate the use of machine learning and artificial intelligence in hernia surgery.

METHODS

The PRISMA guidelines were followed throughout this systematic review. The ROBINS-I and Rob 2 tools were used to perform qualitative assessment of all studies included in this review. Recommendations were then summarized for the following pre-defined key items: protocol, research question, search strategy, study eligibility, data extraction, study design, risk of bias, publication bias, and statistical analysis.

RESULTS

A total of 13 articles were ultimately included for this review, describing the use of machine learning and deep learning for hernia surgery. All studies were published from 2020 to 2023. Articles varied regarding the population studied, type of machine learning or Deep Learning Model (DLM) used, and hernia type. Of the thirteen included studies, all included either inguinal, ventral, or incisional hernias. Four studies evaluated recognition of surgical steps during inguinal hernia repair videos. Two studies predicted outcomes using image-based DMLs. Seven studies developed and validated deep learning algorithms to predict outcomes and identify factors associated with postoperative complications.

CONCLUSION

The use of ML for abdominal wall reconstruction has been shown to be a promising tool for predicting outcomes and identifying factors that could lead to postoperative complications.

Cryoballoon ablation of atrial fibrillation in octogenarians: one year results from the Cryo Global Registry

Background

A few studies have demonstrated the safety and efficacy of cryoballoon ablation (CBA) in elderly patients (≥75 years old) with atrial fibrillation (AF). However, global utilization and outcomes of CBA in the octogenarian population (≥80 years old) have not been reported.

Purpose

To evaluate the efficacy and safety of CBA of AF in patients ≥80 years old.

Methods

The Cryo Global Registry (NCT02752737) is an ongoing, prospective, multicenter registry. In this analysis, 1674 patients with paroxysmal or persistent AF were included in 37 global centers who treated at least one octogenarian with CBA. Analysis cohorts were defined as patients ≥80 and patients <80 years old (control). To address safety issues of CBA in octogenarians, serious procedure-related complications were assessed. Utilizing Kaplan-Meier estimates, 12-month freedom from a ≥30sec AF/atrial flutter (AFL)/atrial tachycardia (AT) recurrence following a 90-day blanking period was evaluated.

Results

The average age of the octogenarians (n=101) was 82±2 years vs 62±10 years in the control group (n=1573). More females were found in the octogenarian population (51.5% vs 35.7%, p<0.01). The ≥80-year-old cohort had lower BMI (26±4 kg/m2 vs 27±5 kg/m2), higher CHA2DS2-VASc-Scores (4.2±1.3 vs 2.0±1.5), and a higher proportion of heart failure (all p<0.01). The patient cohort ≥80 years was similar compared to the control group regarding the AF history (70.3% vs 74.4% paroxysmal AF), years diagnosed with AF (2.9±4.9 vs 3.2±4.8), and left atrial diameter (43±8 mm vs 42±8 mm) (all p>0.05). Success rates of acute pulmonary vein isolation did not differ between the groups (95.0% vs 96.2%, p=0.59). No differences were observed between ≥80- (5.9%) and <80-year-old patients (3.5%) with respect to serious adverse events (p=0.26). Rhythm monitoring, comprising of Holter and 12-lead ECG, was performed on average 3.1±3.1 times in the elder population and 3.2±3.1 times in the control group through 12 months (p=0.84). Efficacy at 12 months was not different between groups, resulting in 80.6% (95% CI: 71.0–87.3%) freedom from AF/AFL/AT recurrence at 12 months in the octogenarians compared to 78.9% (95% CI: 76.7–80.9%) in the control group (p=0.70). Fewer patients were prescribed AADs at 12 months (32.2%, 23.7%) compared to discharge (47.8%, 49.1%), octogenarians and control, respectively. Further, octogenarians were less likely to receive a repeat ablation 3.3% (95% CI: 1.1–9.7%) in comparison to the control cohort 9.2% (95% CI: 7.8–10.8%) (p=0.052). The 12-month Kaplan-Meier estimate of freedom from cardiovascular-related hospitalization was 81.1% (95% CI: 71.7–87.7%) in the octogenarian and 84.8% (95% CI: 82.9–86.6%) in the control group, respectively (p=0.21).

Conclusion

Cryoballoon ablation for the treatment of AF is a safe procedure in octogenarians, with efficacy and complication rates comparable to younger patients.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Medtronic, Inc.

Six year follow-up data on a leadless pacing system real life experience in comparison to data of the prospective trial

Funding Acknowledgements

Type of funding sources: None.

Introduction

The Micra™ leadless intracardiac pacing system has been introduced and implemented into clinical routine in 2015, with its next generation MICRA AV ™ in 2020. Feasibility, implantation safety, and acute success have been proven in the setting of controlled studies. Even apart from controlled studies, this new technology was beneficial for the individual patient. We aimed to report our single center follow-up (FU) data with a follow-up of up to six years.

Methods

In 246 patients (134 men; age: 79±8 y), Micra™ implantation was performed.

Pacemaker interrogation was performed one to seven days after implantation and during FU (1; 3; 6, then every 6 month) up to 72 months. Data were assessed in a real-life setting and compared with existing data of a controlled prospective trial.

Results

The implantation was successful in all 246 attempts with only one pericardial effusion as major complication. During follow up there were two patients developing severe heart failure symptoms resulting in an implantation of a CRT-device and switching of the leadless pacemaker system.

The average acute thresholds, sensing and impedance after system release were: 0.62±0.45V@0.24ms; 10,55±3,61mV and 697±178Ohm. During follow up of up to 5 years neither, pacemaker failure, nor infections were reported. Measurements were reevaluated for long-term thresholds, sensing and impedance: 0.44 ± 0.07V @ 0.24 ms; 17,25 ±4,65 mV and 572 ± 80 Ohm. During five years, no significant changes from acute to long-term measurements were detectable. In comparison to the controlled trial, our measurements of this real-life cohort were very similar.

Conclusion

In a real-life setting, the implantation of the leadless Micra™ system demonstrates a high rate of implantation success without major complications. We were also able to show stable long-term system parameters in the clinical setting of up to six years of follow up with a very good battery longevity of about 12 years.

[Echocardiographic assessment of myocardial function during His bundle and right ventricular pacing]

INTRODUCTION

In patients with pacemaker (PM) therapy, His bundle stimulation (HBS) may lead to a more synchronous activation of the left ventricle (LV) than conventional right ventricular stimulation (RVS). In this study, we investigated to which extent this effect can be objectified by means of contemporary echocardiographic functional imaging.

METHODS

In all, 15 RVS patients (6 women, mean age 76.6 ± 4.1 years) and 15 HBS patients (6 women, mean age 74.6 ± 3.7 years) underwent echocardiography with and without cardiac pacing. Besides LV end-diastolic volume (EDV), ejection fraction (EF), and global strain (GLS), we measured global and regional myocardial work and LV efficiency based on noninvasive pressure-strain loops.

RESULTS

In all HBS patients, optimization of PM settings resulted in immediate changes in myocardial function parameters. With pacing, RVS patients showed a higher decrease in EF and GLS than HBS patients. Global LV work and LV work efficiency decreased significantly only in RVS patients.

CONCLUSION

Changes in regional and global myocardial function can by proven and quantified by functional echocardiography. In patients under PM therapy, HBS shows functional advantages in comparison to conventional RVS.

A virome from ornamental flowers in an Australian rural town

Samples of leaves exhibiting symptoms resembling those caused by virus infection were collected from ornamental street flowers in a rural town in Western Australia. Thirty-seven leaf samples were collected from plants of iris, tulip, lily, daffodil, stock and grape hyacinth. Shotgun sequencing of cDNA derived from leaf samples was done, and analysis showed that about 6% of the sequences obtained were of viral origin. Assembly of virus-like sequences revealed complete or partial genome sequences of 13 virus isolates representing 11 virus species. Eight of the isolates were of potyviruses, one was of a macluravirus, three were of potexviruses, and one was of a bunya-like virus. The complete genome of an isolate originally classified as ornithogalum mosaic virus was genetically divergent and differed in polyprotein cleavage motifs, and we propose that this isolate represents a distinct species. The implications of importing to Australia live plant propagules infected with viruses are discussed.

Comparison of experimental infection with northern and southern Vietnamese strains of highly pathogenic porcine reproductive and respiratory syndrome virus

The aim of this study was to compare the virulence of northern and southern Vietnamese strains of highly pathogenic porcine reproductive and respiratory syndrome virus (HP-PRRSV) as assessed by the level of viral replication, gross and microscopical lung lesions and virus distribution in experimentally infected pigs. The northern and southern Vietnamese HP-PRRSV strains share 96.7% (non-structural protein 2) and 99.3% (open reading frame 5) nucleotide identity. On experimental challenge, approximately 50% of pigs infected with northern Vietnamese HP-PRRSV died, while death was not observed in any pigs infected with southern Vietnamese HP-PRRSV. Mean viral titres (expressed as log(10)TCID(50)/ml) were significantly (P <0.05) higher in sera and lungs from pigs infected with the northern Vietnamese HP-PRRSV than from those infected with the southern Vietnamese strain at multiple time points. Lung lesion scores and PRRSV antigen within pulmonary and lymphoid lesions were significantly (P <0.05) higher in pigs infected with northern Vietnamese HP-PRRSV than in those receiving southern Vietnamese HP-PRRSV at multiple time points. PRRSV antigens were observed in cardiac myocytes, gastric and renal tubular epithelial cells and astrocytes and microglia of white matter in the brain from pigs infected with the northern Vietnamese HP-PRRSV strain only. Thus, genetic similarity did not predict the degree of virulence of these strains. Northern Vietnamese HP-PRRSV was more virulent and had extended tissue tropism when compared with southern Vietnamese HP-PRRSV.

Nasal infection due to Mycobacterium fortuitum

INTRODUCTION

Mycobacterium fortuitum, a rapidly growing non-tuberculous atypical mycobacterium, is commonly found in soil and water. This organism generally causes skin, bone, and soft tissue infections following local trauma or surgical procedures, and in immunodeficient patients. The case reported here is, to our knowledge, the first published report of M. fortuitum nasal infection.

CASE REPORT

The authors report the case of a 3-year-old girl with intranasal tumour-like swelling associated with cervical lymph nodes due to M. fortuitum infection.

DISCUSSION/CONCLUSION

A combination of radical surgical debridement and prolonged therapy with several antimicrobial agents was required to completely eradicate the infection. This case report indicates that non-tuberculous mycobacterial infections should be considered after failure of conventional antibiotic therapy or when classical microbiological tests fail to identify the pathogen responsible for sinonasal and cervical infections.

Antiviral treatment following penetrating keratoplasty for herpetic keratitis

PURPOSE

To assess the effect of antiviral treatment on corneal graft survival following penetrating keratoplasty for herpetic keratitis.

METHODS

Retrospective cohort study of 454 patients receiving primary penetrating keratoplasties (PKs) for viral infection reported to NHS Blood and Transplant (NHSBT) between April 1999 and June 2005. Follow-up data were available on 403 PKs. Kaplan-Meier survival estimates were used to determine graft survival for the three treatment groups: no medication, topical antiviral, and oral antiviral medication. A Cox regression model was used to investigate the combined effects of all additional factors on graft failure. The model was fitted using all pre-operative factors first and then post-operative factors including type of antiviral medication were included.

RESULTS

Patients who received oral antiviral medication post-operatively had consistently better graft survival than those receiving no medication or only topical medication. Patients receiving oral antivirals were less than a third as likely to have a failed graft at 5 years compared with those on no antiviral medication (relative risk (RR) 0.3, CI: 0.2-0.7, P=0.002). Other factors that were found to influence the risk of graft failure were the presence of deep corneal vascularisation (P=0.009), PK performed for therapeutic reasons (P=0.03), large diameter grafts (P=0.04), and experiencing a rejection episode (P=0.003).

CONCLUSION

Oral antiviral treatment reduces the risk of graft failure in patients undergoing primary PK for herpetic keratitis and should be routinely used in this group of patients post-operatively unless contra-indicated.

Contact Lens Wear and IOL Power Calculation Before Cataract Surgery: A Cautionary Tale

PURPOSE

To present a case of erroneous corneal measurements, which led to inaccurate predicted intraocular lens (IOL) power.

METHODS

A 60-year-old woman underwent preoperative assessment for cataract surgery. The predicted IOL power was 19.5 D.

RESULTS

Repeated biometry led to different measurements and an 11.0-D powered IOL was inserted. The predicted IOL power was incorrect, as the patient had worn contact lenses during the preoperative assessment.

CONCLUSIONS

This case demonstrates that errors can occur, and it is essential to fully understand the principles of biometry and the refractive issues of cataract surgery to avoid postoperative refractive errors.

[Dehiscence of the anterior semicircular canal and otosclerosis: a case report]

The dehiscence of the anterior semicircular canal is a new clinical entity, it is necessary to consider this when a gusher occurs during stapedial surgery.

CASE REPORT

We report a rare case of dehiscence of the anterior canal associated with otosclerosis. This was revealed by a gusher during the initial stapedectomy. At 3 months, an obliteration of the dehiscence was necessary by middle cranial fossa approach (persistant vestibular symptoms), seven months later. Revision stapedial surgery resulted in complete closure of the air-bone-gap.

CONCLUSION

High resolution CT scans of the temporal bone are the key to diagnosis. It is necessary to appreciate this pathology with advances in canal and vestibular surgery.

Neurotomie vestibulaire vs. labyrinthectomie chimique dans la maladie de Menière invalidante

OBJECTIVE

To evaluate the efficiency on the vertigos and the impact on the audition of the vestibular neurotomy (VN) and the chemical labyrinthectomy (CL) in patients with severe Menière's disease, in order to determine the precise place for each technique in treatment algorithm.

METHOD

Retrospective study of 71 VN (performed between 1986 and 2003) and 35 CL (performed between 1997 and 2003). These two treatments both aim at obtaining a vestibular deafferentation in order to free definitely the patient of vertigo manifestations. Vestibular results have been assessed by caloric tests performed before and 6 months after treatment. Subjective success was evaluated by searching for recurrent attacks of vertigo and by the AAO-HNS (American Academy of Otolaryngology-Head and Neck Society) scale of subjective evaluation of vertigos (follow-up of 6.4 years after VN and 2.4 years after CL). Pure tone audiometry before treatment and then 6 months later was performed. Complications of two types of treatment were recorded and evaluated.

RESULTS

In 90% of the cases after VN and 86% of the cases after CL, caloric tests indicated a strong vestibular hyporeflexy (hypovalence > 90%). Attacks of vertigo reoccurred in 5.6% of the cases when the hyporeflexy was strong and 85.7% of the cases when it was weak. The quality of the vestibular results on vertigo depends on the degree of hypovalence after treatment. An improvement of the AAO-HNS scale have been obtained in 93% of the cases in the NV group and in 81% of the cases in the LC group. Attacks of vertigo were recurrent in 7% of the patients operated on by VN and 11.4% of the patients treated by CL. Mean pure tone auditory thresholds changed from 50.24 dB HL to 55.64 dB HL (p=0.003) in the VN group and from 69.11 dB HL to 74.51 dB HL (p=0.41) in the CL group. Comparison of the variations of the mean pure tone auditory thresholds before treatment and 6 months after the end of the treatment doesn't show any significant difference between the 2 groups (p > 0.05). Impairment of the audition superior to 20 dB HL was observed in 8.5% of the patients of each group. The auditive results are similar in the 2 groups.

CONCLUSION

These two methods of treatment can not be strictly compared due to several bias in this study. Indeed more patients were treated by VN with a longer follow-up and only the patients with a class C or D audition according to the criteria of the AAO-HNS could be treated by CL. The VN provides a better control of the vertigos than the CL which is an efficient method of treatment in invalidating Meniere's disease. In all the cases, the quality of the results on vertigos depends on the degree of hypovalence after treatment. The auditive results are similar. Since the results of the two treatments are similar, the simplicity of CL encourages us to broaden the indications and to modify the place of the VN in the therapeutic algorithm of Menière's disease.

[Ossiculoplasty with KURZ titanium prosthesis]

OBJECTIVES

Report the functional and anatomic results of ossicular reconstruction by titanium prosthesis.

MATERIALS AND METHODS

Retrospective chart reviews were performed for 111 patients who had undergone titanium ossicular implants between November 1998 and 2002 (61 PORP, 50 TORP). The anatomical and audiometric data were analyzed on average at 3 and 20 months.

RESULTS

At 20 months, the improvement of air-bone-gap mean was 12.7 dB with better results at low frequencies. The global success rate was 66% (PORP 77%, TORP 52%). It decreased significantly in the open techniques. Extrusion rate was low (2/111) and the labyrinthization rate was 3.6%. Twenty patients required a surgical revision (18%). In 9 patients, the prosthesis was too short. At long-term follow-up, the gains were stable in 60 patients, improved in 32 patients and worsened in 19 patients.

CONCLUSION

The success rate is higher in the group of the PORP with the closed technique. The stability of the TORP in open technique still remains problematic. In all cases, the risk of extrusion requires a large cartilage graft recovering the plate of the prosthesis. The high rate of luxation (9/111 prosthesis too short) has led us to increase slightly the length of the prosthesis (+1.22 mm mean).

Résultats à long-terme des cholestéatomes congénitaux de l’oreille moyenne de l’enfant

OBJECTIVES

To report the long term results of congenital cholesteatoma of the middle ear in children.

PATIENTS AND METHODS

Retrospective study of thirty two children with 33 congenital cholesteatoma (1 bilateral cholesteatoma) operated on by the same surgeon. The mean age was 6 years. The most common clinical presentation was unilateral hearing loss. A trans-canal approach was performed in 4 cases and an intact canal wall technique in 29 cases. A two staged surgery was necessary in 28 patients, whom a residual cholesteatoma was observed in 7 patients. A third stage was performed in 11 patients because of a residual cholesteatoma in 2 two cases and a functional failure in 9 cases.

RESULTS

At five years postoperative audiometry (air bone gap inferior or equal to 20 dB HL), a functional success was obtained in 50% of cases.

CONCLUSION

The diagnosis of congenital cholesteatoma must be evoked in every atypical otitis media with effusion or unilateral transmission hypoacusis. The intact canal wall technique in two stages is the most appropriate treatment, since congenital cholesteatoma in children appears aggressive in a well pneumatized mastoid. The choice for an intact canal wall technique is also justified by the ambition of a conservative surgery in the young child. The functional results are generally satisfactory in early diagnosed cases. Thus, ENT and pediatric physicians have a unique role in detecting congenital cholesteatoma in the early period of life, and in ensuring a long term follow-up.

[The jugulotympanic paragangliomas: 41 cases report]

OBJECTIVE

The jugulotympanic paragangliomas (JTP) represents the most frequent tumour of the middle ear but also of the temporal bone, after the acoustic neurinoma. The management of these vascular tumours remains uncleared. The purpose of this study was to report our experience about JTP in the CHU of Grenoble.

MATERIALS AND METHODS

Retrospective study of 41 patients, between 1973 and 1996. Six stages A, 8 stages B and 27 stages C are reported in whom 20 cases (49%) presented an intracranial extension (classification of Fisch). There were 2 familial cases with multiple localisations, in particular carotid. All the patients were divided in 3 groups: surgery or radiation therapy in first intention, surgery followed by radiation therapy.

RESULTS

A total tumor removal without recurrence was achieved by surgery in more than 95% of the cases with 6 years follow-up but was associated with significant morbidity (major cranial nerve injury). We noticed one death by laryngospasme (C2Di2 tumour operated by infratemporal A approach). A stabilization of the tumour was obtained with radiotherapy in first intention in 75% of the cases (5 years follow-up) but with a risk of radionecrosis. A revision surgery was necessary in 3 cases.

CONCLUSION

The comparaison of our different therapeutic management, surgery (23), radiation therapy (16) or combined (2), encourage us to perform a radical surgery whenever possible. Because of the slow rate of growth, the radiotherapy is indicated for older patients, at risk for surgery or extensive tumors. The objectives of the radiation therapy are to obtain a tumoral stabilization with improvement of the symptoms and low morbidity. The management of this rare pathology must be multidisciplinary. The recent discoveries on genes encoding three succinate dehydrogenase subunits (SDHD, SDHB et SDHC) will allow a genetic detection of asymptomatic case and will define the procedures for their management, coordinated by a national network PGL.NET. A retrospective study could also study the real incidence of familial paragangliomas.

[Delayed facial palsy after vestibular schwannoma resection: the role of viral reactivation. Our experience in 8 cases]

OBJECTIVE

To study the role of herpes virus reactivation in the onset of more than three days-delayed facial paralysis (FP) following vestibular schwannoma (VS) surgery and advocate a specific medical management.

MATERIAL AND METHODS

Retrospective study on 8 cases from a series of 348 patients operated on of a VS between 1996 and 2002. Seven of the eight patients were given intravenously acyclovir (30 mg x kg(-1) x d(-1) for 5 days) and methyl-prednisolone (2 mg x kg(-1) x d(-1) for 7 days). A serologic testing looking for specific anti-herpes simplex viruses type 1 and 2 (HSV-2) and varicella-zoster virus (VZV) antibodies at the onset of the FP and 2 weeks later could be done in only 3 cases.

RESULTS

Mean delay of FP onset was 8.75 days. Mean time for recovery with intravenous treatment was 90 days. All treated patients had a House and Brackmann grade 1 recovery. The last one had only a grade 3 after 400 days of evolution: he could not be treated because of postoperative transient psychiatric problems. Serologic testing revealed in those patients in whom it could be done either a high level of anti-HSV or -VZV antibodies at the time of onset or a dramatic increase in anti-HSV or anti-VZV antibodies between the two samples, strongly suggesting a HSV or VZV reactivation.

CONCLUSION

HSV or VZV reactivation can be evocated in most cases of delayed FPs arising in the postoperative course of VSs, suggesting usefulness of emergency-given steroid and acyclovir intravenous regimen to block virus replication and fight secondary oedema and inflammation causative of nerve lesions. Evoked reactivation mechanism is comparable to that already suspected in delayed FP arising with the same delay in middle ear surgical procedures.

[Failure rate and revision surgery in ossiculoplasty with Kurz titanium prosthesis]

Despite its excellent biocompatibility, failures and in particular extrusion of the prosthesis have been described in ossiculoplasty with titanium prosthesis.

OBJECTIVE

Report our experience with revision ossicular recontruction in ossiculoplasty with Kurz prosthesis. Identify causes of failure in ossiculoplasty using the titanium prosthesis.

MATERIAL AND METHODS

Retrospective chart reviews were performed for 110 patients who had undergone titanium ossicular implants between November 1998 and 2002. All patients had undergone ossiculoplasty using titanium middle ear implants. Patients were divided into 2 groups: in group 1 patients underwent revision ossiculoplasty; in group 2 patients had a successful surgery at first stage. Anatomic and functional results have been studied in these two groups. Causes of failures were analysed.

RESULTS

The overall failure rate was 20% (22/110). Twenty patients underwent revision ossiculoplasty. Nine primary failures were attributable to a short implant. Two extrusions were observed. At long term billow-up, the functional gain between the primary and revision ossiculoplasty was comparable.

CONCLUSION

Revision ossiculoplasty is worthwhile for those patients who have failure of the titanium prosthesis in ossiculoplasty. A large cartilage graft interposition is necessary to prevent extrusion. The overall luxation rate observed in our series was mainly due to a too short prosthesis and we recommend now a reconstruction with longer prosthesis.

Congenital pericardial defect and concomitant coronary artery disease

Chest pain is the most common presenting symptom among patients with congenital pericardial defects. A delay in diagnosis of a congenital pericardial defect occurred in a patient because he had concomitant atherosclerotic coronary artery disease. Multiple radiological studies had suggested the diagnosis. The pericardial defect caused myocardial ischemia by obstructing flow in three coronary arteries. Surgical repair of the pericardial defect along with coronary artery bypass grafting was performed to correct the problem.

Pre-transplant corticosteroid use and outcome in lung transplantation

BACKGROUND

The early experience of lung transplantation was plagued with airway anastomotic complications. The use of corticosteroids in the pre-transplant period has been implicated as a major contributing factor in bronchial dehiscence, and many patients have been denied transplantation on the basis of corticosteroid use. We conducted the current study to assess the risks associated with pre-transplant corticosteroid use.

METHODS

We analyzed records of 73 single- and bilateral-single lung transplant recipients who had chronic obstructive pulmonary disease or alpha(1)-antitrypsin deficiency as their underlying disease from 1986 to 1996. Twenty-six patients (steroid group) received daily corticosteroid therapy (prednisone, 1.5 to 40 mg/day) up to the time of transplantation, whereas 47 patients did not receive chronic corticosteroids and had no corticosteroid therapy within 3 months of transplantation (non-steroid group).

RESULTS

The demographic profiles of the 2 groups were comparable. We noted no statistical significances in length of hospital stay, duration of intensive care, and post-operative pulmonary function. The rates of cytomegalovirus infection, acute rejection, bronchiolitis obliterans syndrome, and survival were also similar. The non-steroid group seemed to have a higher rate of bronchial stenosis at 3 years (29% vs 6%, p = 0.03). Bronchial dehiscence did not occur in either study group.

CONCLUSIONS

Pre-transplant use of corticosteroids does not adversely affect outcome following lung transplantation.

Reoperative revascularization of a left internal mammary artery ostial stenosis

A severe ostial stenosis of the left internal mammary artery graft was responsible for unstable angina in a patient with a previous coronary artery bypass graft. Successful revascularization of the lesion was achieved with a subclavian artery-to-left internal mammary artery bypass using a saphenous vein conduit. This procedure was performed through a left thoracotomy incision to avoid potential hazards of a redo median sternotomy.

Effects of left ventricular assist devices on outcomes in patients undergoing heart transplantation

BACKGROUND

Left ventricular assist devices (LVADs) are increasingly being used to "bridge" patients to heart transplantation.

METHODS

Data from 40 consecutive status 1 heart transplantation patients treated with intravenous inotrope therapy (n = 20) or the HeartMate LVAD (n = 20) were retrospectively analyzed.

RESULTS

Baseline clinical characteristics were similar in the two groups. At the time of transplantation, LVAD patients had significantly higher blood pressure and sodium with significantly lower blood urea nitrogen and creatinine. After transplantation, renal failure (52.6% versus 16.7%) and right heart failure (31.6% versus 5.6%) occurred more frequently (p < 0.05) in the inotrope group. Six-month survival after transplantation did not significantly differ in the inotrope or LVAD groups (73.7% versus 88.9%) but event-free survival was significantly (p < 0.05) lower in the inotrope group (15.8% versus 55.6%). Total hospital charges were significantly lower in the inotrope group ($213,860 +/- $107,560 versus $342,620 +/- $104,420), but average daily hospital charges were not different ($3,990 +/- $1,300 versus $4,130 +/- $2,050).

CONCLUSIONS

Status 1 heart transplant patients treated with an LVAD as opposed to inotrope therapy have improved clinical and metabolic function at the time of transplant and improved survival to 6 months after transplant without major complications. Total costs are higher in the LVAD patients but average daily costs are similar.

Left ventricular assist device bridge therapy for acute myocardial infarction

BACKGROUND

Patients with acute myocardial infarction (AMI) complicated by cardiogenic shock have a high mortality rate. Current treatment modalities remain suboptimal for these patients.

METHODS

From April 1995 to March 1998, 7 patients were identified as having AMI associated with cardiogenic shock. All received intraaortic balloon pump assistance, in addition to maximal inotropic support.

RESULTS

The mean preoperative cardiac index was 2.0+/-0.3 L/min/m2 and pulmonary capillary wedge pressure was 23+/-6 mm Hg. Three patients received thrombolytic therapy and 4 patients underwent percutaneous transluminal coronary angioplasty without success. Left ventricular assist devices (LVADs) were implanted as bridge therapy to heart transplantation. One patient died from recurrence of a ventricular septal defect during LVAD support. Six patients were transplanted successfully after mean LVAD support of 59+/-33 days. Five patients are alive and well at a mean follow-up of 898+/-447 days. One patient died 3 days after transplantation from acute allograft dysfunction.

CONCLUSIONS

Timely application of LVADs as bridge therapy to heart transplantation in these critically ill patients can be lifesaving, and should be investigated further.

Temporary ECMO support following lung and heart-lung transplantation

7 days) failure. Seven (78%) patients in the early group were weaned off ECMO and 5 (56%) survived to hospital discharge. In the late group, none of the patients could be weaned off ECMO, yielding 100% mortality. ECMO support instituted for pulmonary graft failure that occurred within 24 hours of transplantation may improve patient survival.

Transcatheter closure of patent foramen ovale for hypoxemia during left ventricular assist device support

A patent foramen ovale with right-to-left shunting was responsible, in part, for profound hypoxemia in a patient who required mechanical support with a left ventricular assist device for cardiogenic shock. The patent foramen ovale was detected with contrast transesophageal echocardiography, and the defect was closed successfully with a transcatheter septal defect closure device.

Pulmonary thromboembolectomy of donor lungs prior to lung transplantation

Successful bilateral single-lung transplantation was performed after pulmonary thromboembolectomy of the donor lungs. The donor lungs were not thought to contain large amounts of pulmonary thromboemboli because they satisfied all the donor selection criteria. This case reinforces the need of not only meticulous inspection of the donor lungs prior to implantation but also the productive use of available donor organs.

Cytotoxic quinolines (part 1). Azolylalkyloxy quinolines and 1-azolylalkyl-4(1H)-quinolones

A series of 4-azolylalkyloxyquinolines and 1-azolylalkyl-4(1H)-quinolones has been synthesized and evaluated for cytotoxicity against various cancer cell lines. 1-Phenyl-1,2,3-triazole and 1-methylpyrazole were found to be the most effective azoles. The length of the alkyl chain was critical, with 8 to 10 carbon atoms being optimal. Several of the compounds were found to be very cytotoxic in vitro towards various cancer cells. Compounds 9o, 10k, and 10r were evaluated in vivo, but were ineffective and exhibited acute general toxicity at higher dosages.

Cytotoxic quinolines (part 2). Azolylalkylamino and-thio quinolines

A series of azolylalkylaminoquinolines and azolylalkylthioquinolines was synthesized and evaluated for cytotoxicity against various cancer cell lines. Structure-activity relationships previously established for azolylalkyloxyquinolines were generally found to apply for the present compounds. The azolylalkylaminoquinolines were found to be more cytotoxic than the corresponding thio compounds. Oxidation of 11a to sulfones 12 and 13 resulted in a reduction of cytotoxicity. Several of the compounds were found to be very cytotoxic in vitro towards different cancer cell lines. Compound 7d, the most cytotoxic in vitro against the P388 cell line in this series, was ineffective in vivo and exhibited significant general toxicity at higher dosages.

Long-term evaluation of immune status in leprosy patients undergoing multiple drug therapy

A long-term survey of leprosy patients of all clinical types, starting at the time of diagnosis, was carried out to monitor clinical, bacteriological and immunological parameters at regular intervals during multiple drug therapy (MDT). The patients were assigned to two groups for treatment following WHO guidelines: paucibacillary (PB) and multibacillary (MB). Immunoglobulin levels, specific antibodies, skin-test responses to different soluble mycobacterial antigens (new tuberculins), and in vitro proliferative responses to mitogens and to antigens were measured during treatment, as were clinical changes, the bacterial index, and clinical improvement. No exact relations between disease activity and IgM antibody levels, both IgM immunoglobulin and specific IgM antibody to a species-specific antigen (ND-O-BSA), could be seen for MB patients. Changes in in vitro cell-mediated immunity and skin-test response seemed to be more directly related to the bacterial load and could reflect the improvement of bacteriological and clinical parameters during MDT.