Climate change and water resources in the Middle East: Vulnerability, socio-economic impacts, and adaption

While the extent of human induced global warming is inconclusive, the vulnerability of natural systems to rapid changes in climate patterns is regarded as one of the most challenging issues in recent years. Water resources are a main component of natural systems that might be affected by climate change. This paper characterises water resources in several Middle Eastern countries and evaluates regional climate predictions for various scenarios using General Circulation Models. Adaptation measures are assessed with a focus on no-regret actions in the context of local socio-economic and environmental frameworks

Pulmonary endarterectomy in the management of chronic thromboembolic pulmonary hypertension

Chronic thromboembolic pulmonary hypertension (CTEPH) is a type of pulmonary hypertension, resulting from fibrotic transformation of pulmonary artery clots causing chronic obstruction in macroscopic pulmonary arteries and associated vascular remodelling in the microvasculature.Pulmonary endarterectomy (PEA) offers the best chance of symptomatic and prognostic improvement in eligible patients; in expert centres, it has excellent results. Current in-hospital mortality rates are 90% at 1 year and >70% at 10 years. However, PEA, is a complex procedure and relies on a multidisciplinary CTEPH team led by an experienced surgeon to decide on an individual's operability, which is determined primarily by lesion location and the haemodynamic parameters. Therefore, treatment of patients with CTEPH depends largely on subjective judgements of eligibility for surgery by the CTEPH team.Other controversies discussed in this article include eligibility for PEA versus balloon pulmonary angioplasty, the new treatment algorithm in the European Society of Cardiology/European Respiratory Society guidelines and the definition of an "expert centre" for the management of this condition

CHEST WALL HEMANGIOMA: A DIFFICULT PREOPERATIVE DIAGNOSIS

We report a case that presents a diagnostic challenge in a 22 year-old female. CT-Scan and MRI showed a soft-density mass (12 cm) causing middle arch erosion of the fifth rib. In this rapidly-growing chest wall tumor a surgical-biopsy was very hemorrhagic and frozen section was unabled to disclose a sarcoma. Angiography and embolization of the feeding arteries were done. The final histopathology pointed out hemangioma. Complete resection was performed without prosthesis interposition. We emphasize two points regarding vascular chest wall tumors: (1) its possibility to mimick a sarcoma, so the surgical planning demands preoperative diagnosis; (2) the positive role of embolization in large and fast-growing lesions

Inhaled nitric oxide does not prevent postpneumonectomy pulmonary edema in pigs

ObjectiveIncrease in lung permeability is an inevitable consequence of pneumonectomy in relation to inflammatory injury and increased perfusion flow. We tested whether inhaled nitric oxide, a potent vasodilatator and anti-inflammatory agent, prevents postpneumonectomy edema in the first 24 hours after pneumonectomy in pigs.MethodsWe assessed hemodynamics, gas exchange, extravascular lung water estimated with the double-indicator dilution method, and lung neutrophil sequestration measured on the basis of lung myeloperoxidase activity at 1 and 24 hours after left pneumonectomy in 14 pigs randomly assigned to inhaled nitric oxide (10 ppm) or control groups.ResultsExtravascular lung water content markedly increased at 1 and 24 hours after pneumonectomy, with no difference between the 2 groups. Hemodynamics did not differ between the 2 groups. Myeloperoxidase activity was higher and Pao2 values were lower in the nitric oxide group compared with in the control group.ConclusionsOver the 24 hours after pneumonectomy, intraoperative inhaled nitric oxide levels neither improved gas exchange nor attenuated accumulation of lung water. On the contrary, they were associated with an increase in lung neutrophil sequestration and deterioration of arterial oxygenation, suggesting the occurrence of an early and toxic effect of nitric oxide

Long-term results after carinal resection for carcinoma: Does the benefit warrant the risk?

ObjectiveWe sought to determine whether the benefit warrants the risk in patients undergoing carinal resection for carcinoma.MethodsThis was a retrospective single-center study.ResultsBetween June 1981 and August 2004, 119 patients underwent carinal resection for carcinoma in our institution. Carinal pneumonectomy was performed in 103 cases (96 right and 7 left pneumonectomies), carinal resection plus right upper lobectomy in 3, carinal resection after left pneumonectomy in 2, and carinal resection without pulmonary resection in 11. Superior vena caval resection was combined with carinal pneumonectomy in 25 patients with bronchogenic carcinoma (13 patients had complete superior vena caval resection with graft interposition). Nine (7.6%) patients died in the hospital or within 30 days of the operation. Follow-up was complete for 117 (98%) patients up to August 2004 or to the date of death. The 5- and 10-year survivals were 44% and 25%, respectively, for patients with bronchogenic carcinoma (n = 100). However, survival was significantly better in patients with N0 or N1 disease (n = 73) than in those with N2 or N3 disease (n = 27; 53% vs 15% at 5 years, respectively). The 5- and 10-year survivals in the remaining 19 patients reached 66% and 48%, respectively, and were best in patients with neuroendocrine carcinoma (100% survival at 10 years) and adenoid cystic carcinoma (69% survival at 10 years).ConclusionsSurgical intervention for carcinoma involving the carina is feasible, with acceptable mortality and good long-term survival in selected patients. The presence of positive N2 disease should, however, be considered a potential contraindication to carinal resection in patients with bronchogenic carcinoma because of the poor long-term survival

Endothelin A receptor blockade improves regression of flow-induced pulmonary vasculopathy in piglets

ObjectivesIn patients with chronic thromboembolic pulmonary hypertension, high flow in unobstructed lung regions may induce small-vessel damage responsible for persistent pulmonary hypertension after pulmonary thromboendarterectomy. In piglets, closure of an experimental aortopulmonary shunt reverses the flow-induced vascular lesions and diminishes the elevated levels of messenger RNA (mRNA) expression for endothelin-1 and endothelin receptor A (ETA). We wanted to study the effect of the ETA antagonist TBC 3711 on reversal of flow-induced pulmonary vascular lesions.MethodsTwenty piglets were studied. In 15 piglets, pulmonary vasculopathy was induced by creating an aortopulmonary shunt. After 5 weeks of shunting, some animals were studied (n = 5); others underwent shunt closure for 1 week with (n = 5) or without (n = 5) TBC3711 treatment. Anti-ETA treatment started 1 week before and ended 1 week after the shunt closure. The controls were sham-operated animals (n = 5).ResultsHigh blood flow led to medial hypertrophy of the distal pulmonary arteries (54.9% ± 1.3% vs 35.3% ± 0.9%; P < .0001) by stimulating smooth muscle cell proliferation (proliferating cell nuclear antigen) and increased the expression of endothelin-1, ETA or endothelin receptor type A or endothelin receptor A, angiopoietin 1, and Tie2 (real-time polymerase chain reaction). One week after shunt closure, gene expression levels were normal and smooth muscle cells showed increased apoptosis (terminal deoxynucleotidyl transferase–mediated dUTP nick end labeling) without proliferation. However, pulmonary artery wall thickness returned to control values only in the group given TBC3711 (33.2% ± 8% with and 50.3% ± 1.3% without; P < .05).ConclusionsAnti-ETA therapy accelerated the reversal of flow-induced pulmonary arterial disease after flow correction. In patients with chronic thromboembolic pulmonary hypertension and severe distal pulmonary vasculopathy, anti-ETA agents may prove useful for preventing persistent pulmonary hypertension after pulmonary thromboendarterectomy

En bloc resection of non-small cell lung cancer invading the thoracic inlet and intervertebral foramina

AbstractObjective: In patients with non-small cell lung cancer invading the thoracic inlet, the transcervical approach does not permit removal of tumor in the intervertebral foramina. We report a variant that lifts this limitation. Methods: Through the transcervical approach, resectability was assessed and tumor-bearing structures were removed, leaving tumor-free margins. Standard upper lobectomy was performed, leaving the lobe in place. A posterior midline approach was used for multilevel unilateral laminectomy, nerve root division inside the spinal canal, and vertebral body division along the midline. The tumor was removed en bloc with the lung, ribs, and vessels through the posterior incision. Fixation of the spine was performed. Medical charts of patients treated with this technique between October 1994 and April 2001 were reviewed retrospectively. Results: Seventeen patients (mean age 45 years) were treated. Resection of the upper lobe and T1 root was done in all 17 cases; 3- and 4-level hemivertebrectomies were done in 13 and 3 cases, respectively; 2-level total vertebral body resection and 2-level hemivertebrectomy were done in 1 case; and resections of the phrenic nerve and subclavian artery were done in 7 and 6 patients, respectively. There were no perioperative deaths or residual neurologic impairments. Postoperative complications were pneumonia (n = 6), cerebrospinal fluid leakage (n = 1), wound breakdown (n = 1), and bleeding necessitating reoperation (n = 1). The overall 3- and 5-year survivals were 39% and 20%, respectively. Conclusions: Non-small cell lung cancers invading the thoracic inlet and intervertebral foramina can be removed completely through a combined anterior transcervical and posterior midline approach, with good results.J Thorac Cardiovasc Surg 2002;123:676-8

Chest wall hemangioma : a difficult preoperative diagnosis

We report a case that presents a diagnostic challenge in a 22 year-old female. CT-Scan and MRI showed a soft-density mass (12 cm) causing middle arch erosion of the fifth rib. In this rapidly-growing chest wall tumor a surgical-biopsy was very hemorrhagic and frozen section was unabled to disclose a sarcoma. Angiography and embolization of the feeding arteries were done. The final histopathology pointed out hemangioma. Complete resection was performed without prosthesis interposition. We emphasize two points regarding vascular chest wall tumors: (1) its possibility to mimick a sarcoma, so the surgical planning demands preoperative diagnosis; (2) the positive role of embolization in large and fast-growing lesions