Elias

Lymph-node ratio is an independent prognostic factor in patients with stage III colorectal cancer: a retrospective study from the Middle East

BackgroundIn this retrospective study, we evaluated the prognostic effect of positive lymph-node ratio (pLNR) on patients with stage III colorectal cancer (CRC). Our paper is the first analysis, to our knowledge, to deal with such data from the Middle East.MethodsWe analyzed the clinicopathological data of 535 patients diagnosed with colorectal cancer at our institution between 1983 and 2003. The 164 patients diagnosed with stage III disease were divided into two categories based on lymph-node ratio (LNR) being the ratio of positive lymph nodes over total lymph nodes dissected: LNR ≤0.4 and LNR >0.4. We used Kaplan-Meier and Cox proportional hazard models to evaluate the prognostic effect of pLNR.ResultsThe 10-year survival rate for the patients with stage IIIA, IIIB and IIIC cancers were 76%, 56% and 0% respectively (P = 0.014). Using pLNR of 0.4 as the cutoff point was found to yield clinically and significant results, with a significant difference in the outcomes of patients with pLNR ≤0.4 compared to those with pLNR >0.4 (hazard ratio = 5.25, 95% confidence interval = 1.2 to 22.1, P = 0.02).ConclusionThe ratio-based staging (pLNR) of CRC is a more accurate and clinically useful prognostic method than the number of positive LNs resected or the total number of LNs retrieved for predicting the course of patients with stage III CRC.

Definitive surgical management of staple line leak after sleeve gastrectomy.

BACKGROUND Sleeve gastrectomy (SG) has become a widely adopted bariatric surgical procedure. The most serious complication is staple line leak (SLL), which is potentially life threatening and, in some patients, becomes chronic and difficult to manage. Definitive surgical management of SLL is effective but seldom published in the literature. OBJECTIVES This study aims to review the outcome of definitive surgical management of SLL after SG, looking at short-term and long-term results. SETTING Single surgeon experience based at a tertiary university hospital in Beirut, Lebanon. METHODS Retrospective review of records of patients with SLL who underwent definitive surgical treatment by the senior author (B.Y.S.) from January 2008 until December 2013. RESULTS Ten patients (50% female) underwent definitive surgical repair during the study period. The mean age, weight, and body mass index at the time of SG were 35 years, 121 kg, and 41.5 kg/m(2), respectively. Most leaks (90%) were at the esophagogastric junction. All underwent multiple operative, endoscopic, or radiologic procedures before definitive surgical repair. Methods of definitive repair included open Roux-en-Y (RY) esophagojejunostomy (70%), open RY gastric bypass (10%), laparoscopic RY esophagojejunostomy (10%), and one laparoscopic RY fistulojejunostomy (10%). Six patients (60%) underwent definitive surgical treatment because of chronic SLL, on average, 26 weeks after leak detection (range 13-39 wk). The other 4 underwent repair earlier, on average 4 weeks after leak detection (1-7 wk). There were no mortalities, and all patients healed without residual leak. Perioperative morbidity developed in 1 of 6 (17%) patients who underwent delayed repair and in 75% of patients who underwent repair early. Patients who underwent early repair were heavier (body mass index 40.5 kg/m(2) versus 30 kg/m(2)) and nutritionally more deplete (albumin 26.7 g/L versus 39.2 g/L). All patients are well at a mean follow-up of 21.6 months (7.5-55.9 mo) with an average percentage excess weight loss of 74% (57%-120%). CONCLUSIONS Definitive surgical management of SLL was uniformly effective with acceptable morbidity. It is indicated in patients with chronic persistent fistula beyond 12 weeks, provided patients are kept in good nutritional state. Some select patients may benefit from this approach in the early phases, but the surgical risks are higher.

Lymph node ratio is an independent prognostic factor after resection of periampullary malignancies: data from a tertiary referral center in the middle East.

Objective:The prognostic impact of nodal involvement in resected pancreatic carcinoma and biliary malignancy has been relatively well established. It has been suggested that lymph node ratio (LNR) may be a more informative way of stratifying patients with node positive disease. Our retrospective review aimed to investigate the significance of such variables and test for independent prognostic factors for survival. Methods:One hundred eighty-three pancreatic and periampullary malignancy cases were registered at the American University of Beirut Medical Center from 1990 to 2004. Of those, 80 had complete data on lymph node status. We analyzed the impact of the number of lymph nodes resected, the number of positive lymph nodes retrieved and LNR using Kaplan-Meier and Cox proportional hazard models. The measured outcome in the KM model was the survival probability at 1, 3, and 5 years while the Cox model was used to measure the hazard ratio (HR) of the previously identified predictors on survival. Results:For the 80 patients included in this analysis, overall survival rates were 65% (54 to 78), 32% (18 to 47), and 21% (8 to 34) were alive at 1, 3, and 5 years, respectively. The median number of resected lymph nodes was 9. In the node positive patients, those who had >12 nodes examined were found to have a significantly better survival (HR=0.24; P=0.013). On multivariate analysis, our model showed the following factors to be significant: age 60 years or older (HR=5.92; P=0.018), poorly differentiated tumors (HR=21.87; P=0.018), number of lymph nodes examined <12 LN (HR=6.77; P=0.022), 3 or more metastatic LN (HR=7.21; P=0.028), and LNR≥0.2 (HR=7.12; P=0.007). Conclusions:After pancreaticodudonectomy for adenocarcinoma of the pancreas and biliary malignancies, ratio-based lymph node staging is an independent and powerful prognostic factor.

Outdoor particulate matter (PM) and associated cardiovascular diseases in the Middle East.

Air pollution is a widespread environmental concern. Considerable epidemiological evidence indicates air pollution, particularly particulate matter (PM), as a major risk factor for cardiovascular diseases (CVD) in the developed countries. The main objective of our review is to assess the levels and sources of PM across the Middle East area and to search evidence for the relationship between PM exposure and CVD. An extensive review of the published literature pertaining to the subject (2000-2013) was conducted using PubMed, Medline and Google Scholar databases. We reveal that low utilization of public transport, ageing vehicle fleet and the increasing number of personal cars in the developing countries all contribute to the traffic congestion and aggravate the pollution problem. The annual average values of PM pollutants in the Middle East region are much higher than the World Health Organization 2006 guidelines (PM2.5 = 10 μg/m(3), PM10 = 20 μg/m(3)). We uncover evidence on the association between PM and CVD in 4 Middle East countries: Iran, Kingdom of Saudi Arabia, Qatar and the United Arab Emirates. The findings are in light of the international figures. Ambient PM pollution is considered a potential risk factor for platelet activation and atherosclerosis and has been found to be linked with an increased risk for mortality and hospital admissions due to CVD. This review highlights the importance of developing a strategy to improve air quality and reduce outdoor air pollution in the developing countries, particularly in the Middle East. Future studies should weigh the potential impact of PM on the overall burden of cardiac diseases.

High-Dose Calcitriol, Docetaxel and Zoledronic Acid in Patients with Castration-Resistant Prostate Cancer: A Phase II Study

Introduction: Docetaxel has become the standard chemotherapy for patients with castration-resistant prostate cancer (CRPC). We wanted to assess the efficacy and safety of a weekly high-dose calcitriol, docetaxel and zoledronic acid combination in CRPC. Patients and Methods: Thirty patients were enrolled to receive calcitriol 0.5 µg/kg orally in 4 divided doses over 4 h on day 1 of each treatment week, docetaxel 36 mg/m2 i.v. infusion on day 2 of each treatment week and zoledronic acid 4 mg i.v. on day 2 of the first and fifth week of each cycle. Treatment was administered weekly for 6 consecutive weeks on an 8-week cycle. Results: Out of 23 evaluable patients, there was a response of prostate-specific antigen (PSA) in 11 patients (47.8%); 6 (26.1%) had a stable PSA level for a median of 4.2 months. The median survival time was 15 months (95% confidence interval 13.9–16.1 months). The regimen was generally tolerated; anemia was the only grade 3/4 hematological toxicity in 2 patients. Conclusions: This regimen was tolerated, and half of the patients had a PSA response. Although our response rates are inferior to some studies using docetaxel, we believe our response rates are acceptable knowing that we are treating CRPC, which still has variable outcomes.

MANAGEMENT OF METASTATIC COLORECTAL CANCER: Current Treatments and New Therapies.

Colorectal cancer represents 8% of metastatic cancers. For decades, the gold standard therapy has been infusional chemotherapy with 5-Fluorouracil (5-FU) associated to folinic acid. The discovery of irinotecan, oxaliplatin and oral forms of 5-FU in the nineties is considered a milestone in the treatment of this disease. Since 2004, targeted therapy with monoclonal antibodies including anti-EGFR and angiogenesis inhibitors showed superiority in terms of mortality compared to conventional therapy. Metastatic colorectal cancer, however, remains an incurable disease. We present the current treatments of metastatic colorectal cancer, the clinical development of these emerging treatments, and their position in the Lebanese health care system.

Outdoor Air Pollution and Cardiovascular Diseases in Lebanon: A Case-Control Study

Outdoor air pollution is increasingly considered as a serious threat for cardiovascular diseases (CVD). The aim of this study is to investigate the association between outdoor pollutants and cardiovascular diseases among adults in Lebanon and to examine the possible moderator effect of cigarette smoking status on this association. A multicenter case-control study was conducted between October 2011 and October 2012. Cases were hospitalized patients diagnosed with CVD by a cardiologist while the control group subjects were free of any cardiac diseases. Information on sociodemographic characteristics, tobacco consumption, self-rated global health, pollution exposure, and other risk factors was collected using a questionnaire. The results of the logistic regression revealed that living near busy highway (OR 5.04, 95% CI (4.44–12.85), P < 0.001) and close to local diesel generator (OR 4.76, 95% CI (2.07–10.91), P < 0.001) was significantly associated with CVD. The association between the CVD and exposure to outside pollutants differed by cigarette smoking status. A clear difference was noted between nonsmokers and current smokers OR 4.6, 95% CI (1.10–19.25) and OR 10.11, 95% CI (7.33–20.23), respectively. Forthcoming studies are needed to clarify the potential link between outdoor air pollution and cardiovascular diseases in Lebanon. Public health interventions must be implemented to reduce air pollution and to improve air quality.

Effects of Nodal Status and Extent of Surgery on Survival in Triple Negative Breast Cancer

Background : Triple Negative Breast Cancer (TNBC) is one of the most aggressive but least understood subtypes of breast cancer. The roles of nodal status and type of surgery while essential in determining the outcomes of patients with TNBC remain controversial and require more examination. Materials and Methods : Clinical and pathological data were retrieved from 1990 until 2001 by retrospective chart review for patients with breast cancer at the American University of Beirut Medical Center. Out of 1455 patients, 524 had complete histological data, of which 138 (26.3%) were diagnosed with TNBC. Median follow up time of patients with TNBC was 3.34 years (Range 0.55 - 10 years). We used the Kaplan-Meier and Cox proportional hazard models to evaluate prognostic effects and estimate hazard ratios (HR). Results : For the 138 patients with TNBC, median age at presentation was 50.91 years (Range 26 - 81). One-year, 5 and 10-year survivals for node-negative patients (N0) were respectively 98.3 %, 91.1% and 74.5 %, compared to 98.5%, 70.3 % and 42.2% for node-positive patients (N1-N3). Numerical nodal staging did not significantly correlate with survival. On multivariate analysis, higher stage (H.R 3.01) and Breast-Conserving Therapy (BCT) had a significant effect on the survival of TNBC patients (H.R 0.195) Conclusion : Lymph node-positivity predicted poorer survival in patients with TNBC. However, within the group of patients with positive LN, the number of positive lymph nodes did not alter survival nor did the tumor size. BCT including radiation therapy had a better effect on survival when compared to mastectomy.

Bone Morphogenetic Protein Usage in Anterior Lumbar Interbody Fusion: What Else Can Go Wrong?

BACKGROUND Bone morphogenetic protein (BMP) graft showed promising outcome during early phases of its use. However, unreported adverse events and off-label use shattered its safe profile and raised concerns regarding its indication. In 2008 the U.S. Food and Drug Administration prohibited its use in anterior cervical spine procedures due to the possibility of edema, hematoma, and need to intubate. At the molecular level, BMPs act as multifactorial growth factors playing a role in cartilage, heart, and bone formation. However, its unfavorable effect on bone overgrowth or heterotopic ossification post spine surgeries has been described. Reported cases in the literature were limited to epidural bone formation. CASE DESCRIPTION We present a rare and interesting case of a 59-year-old female, in whom BMP caused intradural bone growth several years after an anterior lumbar interbody fusion surgery. CONCLUSION Caution must be exercised while using BMPs because of inadvertent complications.

Management of Central Nervous System War Injuries

Traumatic brain and spine injuries are the leading cause of disability and death among civilians and military personnel. These types of injuries are associated with long-lasting impact on quality of life, by affecting daily activities, movement, reasoning, or causing personality changes. Injury types have been changing over the last 100 years due to the difference in war tactics applied during combats. Moreover, since the start of the campaign against global terror, new tools such as the improvised explosive device have been used in war zone with more debilitating traumatic effect on the subjects. However, transport system from battlefield to medical center along with the appropriate and advanced hospital equipment led to decrease in mortality rate among the war injured. Currently, no guidelines have been set for the management of war brain injury (WBI) or war spinal cord injury (WSCI) patients. Many factors should be taken into consideration before deciding on medical versus interventional therapy. In the following chapter, we will be exploring the presentation of patients with WBI or WSCI, diagnostic modalities, treatment, complications, and the long-term outcome.