Video-assisted thoracoscopic surgery versus sternotomy in treating myasthenia gravis: comparison by a case-matched study.

PURPOSE: To clarify the efficacy of a right-sided video-assisted thoracoscopic extended thymectomy (RtVATET) as a surgical alternative for myasthenia gravis (MG) and to determine the optimal timing for a thymectomy. METHODS: Thirty-three patients who underwent RtVATET in two institutes were enrolled in this study. Another 66 paired, traditional trans-sternal extended thymectomy (TET) patients from the registered database were used to compare these two surgical modalities for MG. RESULTS: Mean blood loss was 88.5 ml in RtVATET and 226.8 ml in TET group patients (P < 0.001). Mean operation duration was 207.3 min for RtVATET and 172.8 min for TET patients (P = 0.003). Complete stable remission (CSR) rates and total improvement rates for the RtVATET and TET patients were 42.4% vs 60.6% (P = 0.087) and 87.9% vs 90.1% (P = 0.637), respectively. Furthermore, when we focused on the minor grades (classes I and IIa), TET groups showed significantly better CSR than the RtVATET groups (P = 0.012), but there was no statistically significant difference for the more severe grades (classes IIb and III, P = 0.827). CONCLUSION: Both RtVATET and TET are effective for treating MG, although this study does indicate an advantage for TET. We suggest that a thymectomy should therefore be performed earlier, or that the procedures should be extensive enough to remove all of the tissue that contains thymic tissue.

BDNF Val66Met polymorphism alters sympathovagal balance in healthy subjects.

A common polymorphism of the brain-derived neurotrophic factor (BDNF) gene (Val66Met) has been implicated in anxiety, which is associated with lower vagal activity. We hypothesize that the BDNF Val66Met polymorphism may have a modulatory effect on the cardiac sympathovagal balance. A total of 211 healthy Chinese-Han adults (58 male, 153 female, aged 33.3 +/- 10.3 years) were recruited with three BDNF genotypes: Val/Val (47, 22.3%), Val/Met (108, 51.2%), and Met/Met (56, 26.5%). Autonomic function was assessed via an analysis of heart rate variability. Reductions in high-frequency power, an index for parasympathetic activity, and increases in the low-frequency/high-frequency ratio, an index for sympathovagal balance, were found in subjects bearing the Met/Met genotype as compared to the Val/Val group. These results suggest that an altered sympathovagal balance with relatively decreased parasympathetic activity is associated with the Met/Met genotype, suggesting a potential role for the studied BDNF polymorphism in modulating cardiac autonomic functions.

Acquired fanconi syndrome induced by mixed Chinese herbs presenting as proximal muscle weakness.

We report a rare case with acquired Fanconi syndrome caused by mixed Chinese herbs, initially presenting as waddling gait and lower limb muscle atrophy. From a series of investigations, proximal renal tubule injury with functional defects and Chinese herb nephropathy were discovered. Hypophosphatemic osteomalacia and type II muscle fiber atrophy shown in muscle biopsy of left quadriceps may be associated with the sequelae of ingestion of mixed crude Chinese herbs. Aggressive and early alkali treatment with supplementation of phosphate and Vitamin D restored the patient's metabolic and musculoskeletal abnormalities.

Analysis of outcomes following surgical treatment of thymolipomatous myasthenia gravis: comparison with thymomatous and non-thymomatous myasthenia gravis.

OBJECTIVES: Although significant improvement in myasthenic symptoms has been reported following the removal of thymolipomas, information on surgical outcomes among patients with thymolipomatous myasthenia gravis (MG) is limited. METHODS: This was a retrospective review of patients who underwent extended thymectomy for treatment of MG. RESULTS: From 1995 to 2010, 267 patients with MG underwent extended thymectomy, including 104 with thymomatous MG, 151 with non-thymomatous MG and 12 (4.4%) with thymolipoma. The mean duration of myasthenic symptoms before surgery was greatest in the thymolipomatous group (P < 0.001). The lowest mean age (36.1 years old, P < 0.001) and the lowest preoperative serum anti-acetylcholine receptor antibody titre (P = 0.015) occurred in the non-thymomatous group. More thymic and adipose tissue was removed from the thymolipomatous group compared with the non-thymomatous group (P < 0.001). Regarding surgical outcomes, the rate of stable remission was higher in the non-thymomatous (42.3%) and thymolipomatous (41.7%) groups compared with the thymomatous group (28.8%, P = 0.029). No instances of postoperative exacerbation of MG or tumour recurrence were noted during the postoperative follow-up of patients treated for thymolipoma. CONCLUSIONS: Our results suggest that patients with myasthenia thymolipomatous have surgical outcomes similar to those of patients with non-thymomatous MG and have a mean age at the time of surgery similar to that of patients with thymomatous MG.

Choking incidents among psychiatric inpatients: a retrospective study in Chutung Veterans General Hospital.

BACKGROUND: Choking incidents have long been recognized as a cause of death in people with mental illness. This study attempted to determine the rate of choking incidents and deaths among psychiatric inpatients and identify the risk factors associated with choking incidents. Some preventive measures are also suggested. METHODS: All choking incidents recorded over 3 years in 3 psychiatric wards of Chutung Veterans General Hospital (total of 210 beds) were retrospectively analyzed for demographic variables, psychiatric and medical diagnoses, and drug therapy at the time of the incidents. RESULTS: During the 3-year period, 16 incidents were recorded, involving 11 patients at a rate of 1 incident every 451.4 months of hospitalization per person. Men were 3 times more likely to experience choking incidents than women, and the mean age of choking patients was higher than that of all patients (59.7 vs. 44.4 years). Among the 16 incidents, 3 fatal cases were noted, giving an annual choking death rate of 5.05 per 1,000 persons hospitalized. A high re-choking rate of up to 40.0% was noted, and patients with organic mental disorder had 3.4 times the choking incidence of all patients. The mean antipsychotic dosage of the choking cases was similar to that of all inpatients, but the mean hypnotic dosage of the fatal choking cases was significantly higher. Up to 62.5% of the choking accidents occurred at breakfast, and mantou (a type of steamed bun) was the most common food (9/16) that resulted in the accidents. Of the 11 patients, 9 were rated as "poor" or "very poor" with regard to self-care before the accidents. CONCLUSION: Compared with studies in Western psychiatric inpatients, we have a lower choking incident rate but higher death rate due to choking. We found that older age, male sex, higher dosage of hypnotics, previous choking attacks, organic mental disorder, poor self-care, breakfast time and mantou were possible risk factors associated with choking, in which older age, poor self-care, and higher dosage of hypnotics for fatal cases were statistically significant.

Thymoma is associated with relapse of symptoms after transsternal thymectomy for myasthenia gravis.

Thymectomy is considered a therapeutic option for patients with myasthenia gravis. A myasthenic patient who has not received any treatment for years and shows no signs or symptoms of the disease after operation is still susceptible to a recurrence of myasthenic symptoms. To investigate which factors are related to relapse of symptoms in patients having thymectomy, we conduct a retrospective review in the patients who had experienced complete remission after thymectomy. Complete remission was achieved in 92 of 154 patients who received extended transsternal thymectomy for myasthenia gravis. Among these 92 patients, 20 patients had relapse of symptoms and needed medication again after complete remission was achieved (21.7%). Ten of 22 patients in the thymomatous group had relapse of symptom after complete remission was achieved, while only 10 of 70 patients in the nonthymomatous group had relapse of symptom (P=0.006). Multivariate Cox regression analysis revealed that thymoma was an independent factor for the development of relapse of symptoms. In conclusion, thymoma is an adverse prognostic factor for the MG patients who have experienced complete remission after thymectomy. The patients with thymoma had a greater possibility to develop relapse of symptoms than the patients without thymoma.