Nadine El Kassis

Mycobacterial infection of breast prosthesis – a conservative treatment: a case report

BackgroundBacterial infection is a well-known risk of breast implant surgery. It is typically caused by bacterial skin flora, specifically Staphylococcus aureus and the coagulase negative staphylococci. There have been infrequent reports of breast implant infection caused by the atypical mycobacteria, of which Mycobacterium canariasense not yet reported in the literature.Case presentationThis report summarizes the case of a female patient who underwent mastectomy followed by bilateral breast augmentation and presented approximately three years later with clinical evidence of infected breast prosthesis by Mycobacterium canariasense. One year after thoroughly follow-up, appropriate antibiotherapy and the change of the infected prosthesis, the patient presented no signs of reinfection.ConclusionOur case demonstrates that Mycobacterium canariasense should be considered as a new potential cause of infected breast prosthesis.

Cutaneous metastasis in endometrial cancer: once in a blue moon - case report.

BackgroundCutaneous metastases from internal malignancies are uncommon. Moreover, endometrial carcinoma rarely metastasizes to the skin, with a reported prevalence of 0.8%. Here, we report the case of a 62-year-old woman who developed cutaneous metastases from an endometrial carcinoma.Case presentationWhen admitted to our department, the patient underwent a biopsy that showed the presence of cutaneous metastasis in relation to her initial endometrial cancer, diagnosed 3 years earlier. Thereafter, she was treated with a bilateral uterine artery embolization and chemotherapy. The patient had complications and survived 5 months after the diagnosis of the cutaneous metastasis. She died from sepsis.ConclusionCutaneous metastases of the endometrial carcinoma are usually incurable and suggest an unfortunate prognosis where palliation is the mainstay of patient management.

Breast Density and Breast Cancer Incidence in the Lebanese Population: Results from a Retrospective Multicenter Study

Purpose To study the distribution of breast mammogram density in Lebanese women and correlate it with breast cancer (BC) incidence. Methods Data from 1,049 women who had screening or diagnostic mammography were retrospectively reviewed. Age, menopausal status, contraceptives or hormonal replacement therapy (HRT), parity, breastfeeding, history of BC, breast mammogram density, and final BI-RADS assessment were collected. Breast density was analyzed in each age category and compared according to factors that could influence breast density and BC incidence. Results 120 (11.4%) patients had BC personal history with radiation and/or chemotherapy; 66 patients were postmenopausal under HRT. Mean age was 52.58 ± 11.90 years. 76.4% of the patients (30–39 years) had dense breasts. Parity, age, and menopausal status were correlated to breast density whereas breastfeeding and personal/family history of BC and HRT were not. In multivariate analysis, it was shown that the risk of breast cancer significantly increases 3.3% with age (P = 0.005), 2.5 times in case of menopause (P = 0.004), and 1.4 times when breast density increases (P = 0.014). Conclusion Breast density distribution in Lebanon is similar to the western society. Similarly to other studies, it was shown that high breast density was statistically related to breast cancer, especially in older and menopausal women.

Placenta accreta and beyond: Aesop's fables

will; in fact, an earlier Danish nationwide cohort study (10) referenced in our article, did include register-based data on induced abortions from 1973 onwards, but not, in contrast to our study, illegally induced abortions. We agree with Mr. Carroll that the inclusion of in situ carcinomas would have increased the number of cases. We were, however, reluctant to do this, because reporting of this type of cancer is probably incomplete. Therefore, the inclusion of in situ carcinomas might have introduced selection bias in our study. We agree with Mr. Carroll that it would be interesting to compare the incidence in our data with data from the national population. However, the incidence rate of breast cancer does not necessarily affect the hazard ratio. This will only be the case if the association between induced abortion and breast cancer differs between, for example, Copenhagen and other areas.

Placenta accreta and beyond: Aesop is not Zeus.

Sir I thank Professor Matsubara for his reply (1). First of all, I would like to insist that the pathology we are dealing with might be more frequent in countries where the cesarean section rate is very high as compared with Japan, where abnormal placentation seems to be a relatively rarer event (1,2). On the other hand, I agree with him that few persons in the same department or in other departments are able to reproduce the procedure as we previously described it. The difficulty in operating placenta accreta or percreta originates in the pathology itself rather than in the surgical technique; the variable aspects of the pathology and its presenting mode require a standardized technique as well as a great surgical versatility on the part of the operator. In our opinion, an anterior classical hysterectomy technique instead of a posterior retroperitoneal approach exposes the surgeon to a much greater risk of massive hemorrhage. Placenta percreta almost never invades posteriorly, unless the patient has previously had posterior hysterotomies, but we have seen it repeatedly invading laterally and anteriorly far beyond the usual surgical landmarks of the classical anterior hysterectomy. The ascending branch of the uterine artery for instance, which is habitually clamped to perform a classical hysterectomy, is almost always involved inside the placental mass. Posterior incision in the avascular plane of the pouch of Douglas in between the utero-sacral ligaments guarantees minimum or no bleeding; the pouch of Douglas is almost always free, unless there is a superimposed pathology such as endometriosis. Similarly, the retroperitoneum is very rarely involved, leaving a safety margin for the surgeon. This is exactly the same approach that we regularly use for ovarian cancer debulking and posterior exenterations. Posterior retroperitoneal incision is a standardized pathway (3). I am not reinventing the wheel. Nonetheless, the procedure should not be performed by everyone. A surgeon who will only be encountering the pathology once in a lifetime, as Professor Matsubara puts it, will have to pass the operation on to others who have the appropriate expertise in pelvic surgery; in an emergency situation, these cases should be addressed to specific centers and trained surgeons and not be operated on in sub-optimal conditions by persons who will simply apply “extrapolated” or “democratized” techniques. It is worth noting here that the cases must be diagnosed early in gestation and planned ahead of time. Allowing untrained, insufficiently trained or inexperienced gynecologists to perform such a procedure is clearly compromising patient security. We have witnessed cases of cataclysmic hemorrhage that barely allowed us enough time to drape the patient and start the operation in a rush to extract the baby and perform the hysterectomy. Ureteral stents could not have been placed in such a situation. I am somehow astonished that surgeons in Professor Matsubara’s team who could easily place ureteral stents in an emergency case, could not also perform incision of the pouch of Douglas and retroperitoneal dissection. The type of procedure we are describing is quite similar to oncologic surgery operations and therefore such a specialist could readily manage it.

Clinical research ethics review process in Lebanon: efficiency and functions of research ethics committees – results from a descriptive questionnaire-based study

BackgroundClinical trials conducted in Lebanon are increasing. However, little is known about the performance of research ethics committees (RECs) in charge of reviewing the research protocols. This study aimed to assess the level of adherence to the ethics surrounding the conduct of clinical trials and perceptions of team members regarding roles of the RECs during the conduct of clinical trials in Lebanon. The research question was: Are RECs adherent to the ethics surrounding the conduct of clinical trials (chapters II and IV in ‘Standards and Operational Guidance for Ethics Review of Health-related Research with Human Participants’ in Lebanon?’MethodsThis was a quantitative and descriptive questionnaire-based study conducted among RECs of university hospitals in Lebanon. The questionnaire had to be completed online and included general questions in addition to items reflecting the different aspects of a REC performance and effectiveness. All the questionnaire was assigned a total score of 175 points. General information and questions assigned point values/scores were analysed using descriptive statistics: frequency and percentage, mean score ± standard deviation.ResultsTen RECs participated in the study (52 persons: four chairs, one vice-president, 47 ordinary members). Forty-seven (90.4%) had previous experience with clinical research and 30 (57.7%) had a diploma or had done a training in research ethics. Forty-one percent confirmed that they were required to have a training in research ethics. All RECs had a policy for disclosing and managing potential conflicts of interest for its members, but 71.8% of participants reported the existence of such a policy for researchers. Thirty-three point three percent reported that the RECs had an anti-bribery policy. The questionnaire mean score was 129.6 ± 22.3/175 points reflecting thus an excellent adherence to international standards.ConclusionInadequate training of REC members and the lack of anti-bribery policies should be resolved to improve their performance.

Case series of outcomes of a standardized surgical approach for placenta percreta for prevention of ureteral lesions

To report the outcomes of women with placenta percreta who were surgically treated by a specialized technique based on gynecologic oncology experience, and to demonstrate its safety in preventing ureteral lesions and reducing blood loss.

Cerebral Aneurismal Rupture with Subarachnoid Hemorrhage during Pregnancy : A Case Report

BACKGROUND Intracranial hemorrhage due to arteriovenous malformation or intracranial aneurysm is a rare but severe complication of pregnancy with maternal and fetal mortality of 20% and 33% respectively. Whether to deliver the patient first, or to treat the aneurysm first is still controversial, but an emergency cesarean section followed by aneurismal treatment appears to be a widely accepted strategy in pregnant women with cerebral aneurysmal complications. CASE A 38-year-old patient, G3P2A0, presented at 36 gestational weeks with a diffuse bilateral subarachnoid hemorrhage with fourth ventricle bleeding and hydrocephalus. She had a cerebral aneurysm of the left posterior communicating artery on arteriography. A cesarean section was performed on the first day of admission, and an external ventricular derivation with clipping of the aneurysm on the left posterior communicating artery were done immediately after the cesarean section. Mother and newborn were discharged from hospital in a good health status except Brocas aphasia in the mother. CONCLUSION In the absence of categorical recommendations, we stress the role of combined care by both neurosurgeons and obstetricians, on a case to case basis according to gestational age, mother neurological status and experience of caregivers.

Surgical Management of Pelvic Organ Prolapsein Women : How to Choose Tee Best Approach

Although benign, pelvic organ prolapse is a real public health problem, affecting mostly women above sixty-five. Eighty-year-old women have an 11.1% lifetime risk of undergoing surgery for prolapse or stress urinary incontinence and 29% will need a second procedure. Surgical approach may be abdominal (sacrocolpopexy by laparotomy, laparoscopy or robot-assisted) or vaginal (autologous, or prosthetic reinforcement). In addition to anatomical correction, surgical objectives include: improvement of the patients quality of life, prolapse symptoms relief, normal urinary, digestive and sexual functions and especially, avoiding iatrogenic sequelae. Thus, the choice of the surgical approach does not only depend upon the site and the severity of the prolapse. Urogynecological surgeons should take into consideration the patients expectations and life style, her age--a determinant factor in deciding upon the best approach -, and her relapse risk factors. They should master both approaches, and the management of surgical complications. Therefore, an apprenticeship in a reference pelviperineology center is a must. In addition, surgeons should be aware of and consider contraindications to each procedure, for instance contraindications to transvaginal prosthesis reinforcement like risk factors of bad healing or infection. Urogynecology specialists have to take into consideration known anatomical and functional results of each technique as cited in the medical literature and act in accordance with international recommendations. The surgerys main objective is to ameliorate the patients discomfort and her quality of life without causing iatrogenic dysfunctional symptoms (urinary, digestive, sexual). The pelvic organ prolapse being a benign pathology, the patients satisfaction is the main marker of the procedure success. In short, regarding the surgical management of pelvic organ prolapse in women the answer to the question How to choose the best approach? is not binary. It depends on several factors, and regardless of the choice, it must