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BACKGROUND: Oil and gas industry workers appear to suffer from anxiety and depression more frequently than the general population. AIMS: To establish the prevalence of depression and anxiety symptoms among offshore workers working for an oil and gas company and to identify the main stressors that lead to symptoms of these disorders. METHODS: One thousand seven hundred and forty-seven workers employed in an offshore oil and gas company in the Middle East completed the Generalized Anxiety Disorder (GAD-7) and Patient Health (PHQ-9) questionnaires. Anxiety and depressive symptoms were estimated from these surveys. RESULTS: Anxiety and depression symptoms were reported by nearly 15% of workers surveyed. Ordered logistic regression analyses showed that age, rotation length, years of service and local origin (versus expatriate) were significant predictors for symptoms of anxiety. With adjustment for age, older local workers had a lower risk of anxiety symptoms than expatriates. CONCLUSIONS: Younger workers, workers with longer rotations and those with fewer years of service were more likely to report anxiety symptoms. In addition, older local workers and expatriates had a lower prevalence of anxiety symptoms than younger local workers. Future recommendations should address improvements in psychological health of offshore workers in the gas and oil industries.

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We present a case of a male patient with a breast mass, found to be a malignant mesothelioma. We discuss the diagnostic challenges, the need for heightened awareness in suspected cases, the histological classification of mesotheliomas and the treatments available. We believe this to be the second reported case of a mesothelioma presenting as a breast mass.

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Amyotrophic lateral sclerosis (ALS) is a devastating neurological disorder affecting upper and lower motoneurons. Since immune disbalance is known to be an important manifestation of the disease, working with the familial ALS rat model, hSODG93A (containing multiple copies of the human SOD1 G93A mutation), we were particularly interested in following by live magnetic resonance imaging (MRI) the immune cells labeled by ultra small paramagnetic iron oxide (USPIO) nanoparticles. In addition, microglial activation was studied by immunocytochemistry. MRI of USPIO labeled Tcells revealed CD4+ lymphocyte infiltration in the midbraininterbrain region while the CD8+ cells were more confined to the brainstem region. By way of gadolinium (Gd) contrast it was also confirmed that the bloodbrain barrier (BBB) was compromised. Moreover, it was revealed that the regions of BBB breakthrough were congruent with the MRI foci of Tcell infiltration. Immunocytochemistry revealed microglial activation and fusion, possibly phagocytic interactions with neurons in the hippocampus and brainstem. These observations prove the existence of an elaborate inflammatory process in the brain of hSODG93A rats, and also demonstrates the complexity and multifocality of ALS as having its inflammatory manifestations also in the central nervous system (hippocampus) distinct from clinically described motor foci of degeneration.

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In the last twenty years lung transplantation has become an established treatment for end-stage lung failure refractory to medical management. Over this time, better short and long-term results have been achieved due to improvements in organ procurement, perfusion and preservation strategies, newer immunosuppressant regimes and better post-transplant care. The limiting factor for the number of lung transplantation procedures performed is the shortage of available donor organs. This results in longer waiting times for listed patients, with a substantially increased risk of dying prior to transplantation, especially in the paediatric population. Several surgical strategies have evolved to overcome the donor shortage, with lobar transplantation becoming a viable alternative. We describe our initial experience with two young patients with end-stage cystic fibrosis (CF) who required lung transplantation. Given their small size it was not possible to transplant an entire lung from an adult donor in each hemithorax. We describe lobar transplantation as a technique used to overcome this, in the first such operation in Belgium.

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An endovascular stent graft was successfully used in the management of a patient with multiple injuries, who sustained an acute type B dissection of the thoracic aorta. We discuss the multidisciplinary approach taken, the contra-indications of conventional surgery, and the radiological imaging employed. We conclude that stent grafts can be safely deployed without morbidity or mortality in a multiply injured patient.

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We describe a patient who developed a primary, thigh adductor-muscle abscess caused by Nocardia asteroides 3 years after orthotopic cardiac transplantation. Nocardia was diagnosed by microbiologic culture and responded fully to a prolonged course of cotrimoxazole. The patient remains free of local or systemic disease at 2 years follow-up.

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BACKGROUND: Tracheal obstruction secondary to benign proliferation of granulation tissue is a difficult problem to address if tracheal resection is contraindicated. Some patients may benefit from Nd:YAG (neodymium: yttritium-aluminum garnet) laser fulguration or tracheal stenting. If uncovered expandable metallic stents are employed granulation tissue can regrow and proliferate through the mesh, thereby obstructing the lumen once again. Covered metallic stents confer the advantage of preventing granulation tissue proliferation and therefore maintain patency of the tracheal lumen. METHODS: Two patients who developed tracheal obstruction secondary to proliferating granulation tissue formation after tracheostomy and who were medically unfit for prolonged general anesthesia were successfully treated using covered expandable metallic tracheal stents. RESULTS: Each patient demonstrated a significant improvement in respiratory status, and in both patients, at 6 and 9 months' follow-up, stent position has not changed, tracheal lumen remains patent, and there has been no proliferation of granulation tissue through the stent. CONCLUSIONS: Covered expandable metallic stents should be considered in the management of patients with proliferating tracheal granulation tissue when tracheal resection is contraindicated.

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BACKGROUND: Tracheostomy after cardiac operation through a median sternotomy is believed to increase the risk of mediastinitis, leading to debate as to whether early tracheostomy is safe in these patients. METHODS: A record search of patients undergoing cardiac operation through median sternotomy was done. Day and duration of tracheostomy were correlated to day of positive bacteriological evidence and clinical outcome for the patient. The method of tracheostomy was also recorded. RESULTS: Of 174 cases, 4 patients had mediastinitis, 3 before tracheostomy was performed. Of these three patients, 2 survived and the third died of multiorgan failure 46 days after the procedure. The fourth patient, on immunosuppressive therapy for severe rheumatoid arthritis and pulmonary fibrosis, had tracheostomy performed at primary operation, developed fatal mediastinitis after 6 days, and died 18 days postoperatively of multiorgan failure. Of the tracheostomies performed, 24 (14%) were percutaneous, and 110 (63%) were achieved using standard surgical techniques (in 40 cases type was unrecorded). In 72 cases (41%), tracheostomy was performed on or before day 7, 11 (6%) being performed before 48 hours. Mortality occurred in 38 (22%). CONCLUSIONS: There is no demonstrable relationship between early tracheostomy and mediastinitis in median sternotomy patients.

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This study describes a patient who developed decompensated liver disease secondary to reactivation of hepatitis B infection 20 months after single lung transplantation following augmentation of immunosuppression to treat allograft rejection. Discussion focuses on the virologic and management issues of this case and reviews the approach taken when considering patients with chronic hepatitis B infection for lung transplantation.

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BACKGROUND: A proportion of heart transplant recipients develop poor graft function in the absence of cellular infiltrate in endomyocardial biopsies or transplant associated coronary artery disease. The condition has a poor prognosis and its aetiology is poorly understood. We report encouraging intermediate term results with total lymphoid irradiation (TLI) in the management of this condition. METHODS: Eleven adult cardiac transplant recipients who developed severe allograft dysfunction (NYHA class-4) at a median period of 4 months after orthotopic heart transplantation were successfully treated with TLI. Endomyocardial biopsies and coronary angiography were normal in each patient and biventricular failure developed in spite of immunosuppression with Cyclosporin-A, Azathioprine, oral Prednisolone, Cyclophosphamide and intravenous Methylprednisolone therapy. Total lymphoid irradiation was given with standard Mantle and inverted Y-fields over ten treatments to achieve a cumulative dose of 8 Gy. RESULTS: Each patient had a significant improvement in clinical response and in ventricular performance within 2 months of commencing TLI. Nine patients are currently well (four NHYA class-1, five NHYA class-2) at 4-48 (median 26) months following TLI. Two patients died; one from bacterial septicaemia and one as a consequence of chronic renal failure. Three patients developed opportunistic infection which was successfully treated with appropriate antimicrobial agents. An Ebstein-Barr virus associated lymphoproliferative disorder occurred in one patient and was successfully treated by reduction in immunosuppression and high dose Acyclovir. Two patients developed transient bone marrow suppression. CONCLUSION: The intermediate term results of TLI in the management of poor graft function in cardiac transplant recipients with normal endomyocardial biopsies and coronary angiography are encouraging. Although complications of opportunistic infection, bone marrow suppression and lymphoproliferative disorder occurred, treatment was successful in each case.

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