Pregnancy in Women with Metastatic Sarcomas.

Successful pregnancy in women with metastatic cancer is rare in the published literature. We report here on four women with sarcoma who started and conducted their first pregnancies while in metastatic disease. All four pregnancies were first pregnancies, and all four women are long-term survivors from 20 to 248 months after pregnancy. One patient had three pregnancies. All four women stopped systemic cancer treatment during their pregnancies, and two had RECIST progression during treatment interruption. Three patients still have unresectable metastatic disease, whereas one is in complete remission. In selected metastatic sarcomas with indolent courses, successful pregnancies are possible with no or minor impact on cancer progression and with prolonged life duration after pregnancy. As metastatic cancer becomes more often a chronic disease, this possibility opens important practical and ethical questions on how to best to advise women of childbearing age with metastatic cancers who are long-term survivors.

Correction to: Safety considerations regarding Methotrexate of label use in tubal ectopic pregnancy.

In the original article publication, the authors given name and family name were interchanged.

Haematogenous prosthetic knee infections: Prospective cohort study of 58 patients.

BACKGROUND: Prosthetic joint infection (PJI) is a rare (incidence, 0.15% to 0.9%) but serious complication of knee arthroplasty. Haematogenous PJI of the knee (KhPJI) which accounts for 10% of cases, has been less studied than PJI due to other mechanisms. The primary objective of this study in patients with KhPJI of the knee was to determine the 2-year infection eradication failure rate after either exchange arthroplasty or arthrotomy/synovectomy/irrigation (ASI), combined with prolonged peri-operative antibiotic therapy, at a referral centre for complex osteo-articular infections. HYPOTHESIS: ASI within 2 weeks after symptom onset and one-stage exchange arthroplasty produce similar 2-year success rates in patients with KhPJI of the knee. MATERIAL AND METHODS: A prospective observational cohort study was performed in patients managed for PJI of the knee between 2003 and 2015. The primary outcome measure was the occurrence of a septic event or of KhPJI -related death during a minimum follow-up of 2 years. RESULTS: Of 265 patients with PJI after total knee arthroplasty, 58 (22.1%) had KhPJI with onset more than 3 months after the last arthroplasty procedure and were included in the study. Among them, one-third had immune deficiencies. The most common causative organisms were streptococci (n=25, 43%) and Staphylococcusaureus (n=20, 34%). The primary focus of infection was identified in only 64% of patients and was most often cutaneous (n=19, 33%) or dental (n=11, 19%). A septic event or KhPJI-related death occurred in 5/34 (15%) patients after one-stage exchange arthroplasty and 6/19 (32%) patients after ASI within 15 days after symptom onset (p=0.03). Patient characteristics, type of prosthesis, and causative organism were not significantly associated with failure to eradicate the infection. CONCLUSION: ASI carried a high failure rate despite being performed within 15 days after symptom onset. One-stage exchange arthroplasty seems to be the best surgical option, particularly as the exact time of symptom onset may be difficult to determine. Identifying and eradicating the primary focus of infection is crucial. LEVEL OF EVIDENCE: II, low-powered prospective cohort study.

Can early ßhCG change and baseline progesterone level predict treatment outcome in patients receiving single dose Methotrexate protocol for tubal ectopic pregnancy?

INTRODUCTION: We aimed to assess the prognostic significance of early ßhCG change and baseline progesterone level on treatment outcome among women receiving single dose Methotrexate protocol for tubal ectopic pregnancy (EP). MATERIAL AND METHODS: Retrospective study involving all consecutive patients diagnosed with EP and receiving Methotrexate therapy form January 2015 to December 2016. Patients were stratified into 2 groups according to treatment outcome: success group (n = 66) involved women who displayed complete resolution of serum ßhCG levels following a single course of Methotrexate; failure group (n = 55) included patients who required repeated Methotrexate administration and/or surgical management. Predictive performances of baseline progesterone and ratio"ßhCG level on day 4/ ßhCG level on day 1″ (d4/d1) on treatment outcome were assessed using Receiving Operating Characteristics curves. RESULTS: The ratio d4/d1 displayed good performances in predicting treatment outcome (AUC = 0.826). A ratio ≤ 0.7 was associated with a success rate of 94% after 1 course of Methotrexate and 100% after 2 courses. In contrast, a ratio >1.7 was associated with a failure rate of 100%. Conversely, baseline progesterone showed poor performances (AUC = 0.611). CONCLUSIONS: Patients with extreme ßhCG changes (n = 33) on day 4 might benefit from a more personalized approach: simplified monitoring in those with a decline ≥30%, anticipated second course of treatment in those with an increase > 70%.

Fetal and neonatal abnormalities due to congenital rubella syndrome: a review of literature.

OBJECTIVE: Rubella virus infection during the first trimester of pregnancy can cause congenital rubella syndrome (CRS). We aimed to describe the abnormalities in order to define the ultrasound features to look for when performing prenatal scans. The goal of this review is to focus specifically on the signs of CRS accessible to prenatal diagnosis. METHODS: We analyzed every case of CRS described before and/or after birth that we identified in the Pubmed database and classified them as accessible or not to prenatal diagnosis. RESULTS: The most frequently reported malformations accessible to prenatal diagnosis were: cardiac septal defects, pulmonary artery stenosis, microcephaly, cataract, microphtalmia, and hepatosplenomegaly. CONCLUSION: This extensive literature review shows that the ultrasound features of CRS are not well known, even though rubella was the first teratogenic virus described. This review will help clinicians in the management of rubella during pregnancy by clarifying the findings to be sought.

Undergraduate medical education in Lebanon.

BACKGROUND: Lebanon, located on the eastern side of the Mediterranean Sea, is a multi-confessional, multi-cultural country with a long history of medical education. One of the first medical schools in the Middle East was established in Beirut, Lebanon's capital, in 1868. AIMS: The aim of this article is to provide an overview of the current status of undergraduate medical education in Lebanon. METHODS: The descriptive data were collected from the medical schools' institutional website and the analysis was performed by the authors. No statistical analysis was required. RESULTS: Currently, seven medical schools serve a population of 4 million people. Those schools adopt different curricular systems reflected in their admissions, study length, and language of instruction, mainly based on the French or the American model. CONCLUSION: Lebanon's diversity translates into medical education, with the various schools adopting different systems.

The effect of low-dose intravenous ketamine on continuous intercostal analgesia following thoracotomy.

Ketamine, a noncompetitive N-methyl-d-aspartate antagonist, provides analgesia and prevents chronic pain following thoracotomy. The study was aimed to assess the effect of intravenous low-dose ketamine on continuous intercostal nerve block analgesia following thoracotomy. The study was a prospective, randomized, double-blinded, and placebo-controlled clinical study, performed in a single university hospital. Sixty patients, undergoing elective lobectomy through an open posterolateral thoracotomy, were included. For postoperative pain, all patients received a continuous intercostal nerve block with bupivacaine plus intravenous paracetamol and ketoprofen. In addition, patients were randomized to have intravenous ketamine (0.1 mg/kg as a preincisional bolus followed by a continuous infusion of 0.05 mg/kg/h) in group 1 or intravenous placebo in group 2. Patients reporting a visual analog scale pain score at rest ≥40 mm received intravenous morphine sulfate as rescue analgesia. The following parameters were assessed every 6 hours for 3 postoperative days: Visual analog scale pain scores at rest and during coughing, requirement of rescue analgesia with morphine, Ramsay sedation scores and psychomimetic adverse effects. Both the groups were statistically comparable regarding visual analog scale pain scores at rest (P=0.75) and during coughing (P=0.70), number of morphine deliveries (P=0.17), cumulative dose of rescue morphine (P=0.2), sedation scores (P=0.4), and psychomimetic adverse effects (P=0.09). Intravenous low-dose ketamine, when combined with continuous intercostal nerve block, did not decrease acute pain scores and supplemental morphine consumption following thoracotomy.

Myocardial extraction of intracellular magnesium and atrial fibrillation after coronary surgery.

BACKGROUND: The effects of magnesium loading on the incidence of atrial fibrillation following coronary artery bypass graft surgery (CAGB) are equivocal. None of the previous studies assessed the influence of myocardial extraction of magnesium in these settings. The current trial aims to elucidate whether the incidence of atrial fibrillation following CABG is affected by the preoperative rate of myocardial extraction of magnesium. METHODS: The ethical committee approved the study protocol. 113 patients (94 male, mean age 63 ± 11 years) planned for elective CABG surgery under normothermic cardiopulmonary bypass were prospectively included. Preoperative independent variables included preoperative treatment, electrocardiographic abnormalities, left ventricular ejection fraction estimation, left atrial size, creatinine clearance and assays of plasma and intracellular magnesium, calcium, albumin, potassium and ionized calcium, drawn preoperatively from the coronary sinus and the aortic root. The covariates - including the rate of myocardial extraction of magnesium - were entered in a logistic regression model to predict the odds of atrial fibrillation. RESULTS: The incidence of post operative atrial fibrillation was 16%. A rate of myocardial extraction of intracellular magnesium ≥ 7% increases fivefold the multivariate risk of postoperative atrial fibrillation (p < .01). Advanced age was also significantly associated to postoperative atrial fibrillation. CONCLUSIONS: This study suggests that a preoperative rate of myocardial extraction of intracellular magnesium ≥ 7% could be a new and a potent predictive factor for postoperative atrial fibrillation.

Pulse pressure variation predicts fluid responsiveness in elderly patients after coronary artery bypass graft surgery.

OBJECTIVE: To assess the ability of pulse pressure variation to predict fluid responsiveness in mechanically ventilated elderly patients after coronary artery bypass graft surgery. DESIGN: A prospective, interventional study. SETTING: An academic, tertiary referral hospital. PARTICIPANTS: Sixty patients >70 years old and mechanically ventilated after coronary artery bypass graft surgery. INTERVENTIONS: Intravascular volume expansion using 6% hydroxyethyl starch solution, 7 mL/kg over 20 minutes. MEASUREMENTS AND MAIN RESULTS: Heart rate, arterial blood pressure, pulse pressure variation, central venous pressure, pulmonary artery occlusion pressure, and stroke volume index were measured immediately before and after volume expansion. Fluid responsiveness was defined as an increase in stroke volume index ≥ 15% after volume expansion. Forty-one patients were fluid responders and 19 patients were nonresponders. In contrast to central venous pressure or pulmonary artery occlusion pressure, pulse pressure variation was higher in the responders than in the nonresponders (22 ± 6% v 9.3 ± 3%, p = 0.001) and correlated with the percent changes in the stroke volume index after volume expansion (r = 0.47, p = 0.001). The area under the receiver operating characteristic curve for pulse pressure variation was 0.85 (95% confidence interval 0.75-0.94). The threshold value of 11.5% allowed the discrimination between responders and nonresponders with a sensitivity of 80% and a specificity of 74%. CONCLUSIONS: Pulse pressure variation is a reliable predictor of fluid responsiveness in mechanically ventilated elderly patients after coronary artery bypass graft surgery.

[Does nasal decontamination reduce the incidence of infections after cardiac surgery?]. / La décontamination nasale diminue-t-elle la fréquence des infections après chirurgie cardiaque?

INTRODUCTION: Mupirocin applied to the anterior nares four times daily usually eliminates Staphylococcus aureus, including methicillin resistant, within 48 hours. Prophylactic intranasal mupirocin is safe, inexpensive and effective in reducing the overall sternal wound infection after open-heart surgery. This study was designed to determine whether decreasing nasal bacterial colonization by applying mupirocin intra nasally decreases mediastinal, sternal, pulmonary and cutaneous infections after open-heart surgery. MATERIAL & METHODS: After institutional approval and informed consent, 392 patients were included in a randomized, prospective study. Nasal cultures were taken for all patients before surgery. Patients were divided in two groups: Group I (n = 190) receiving mupirocin in the anterior nares 4 times daily for 48 hours before surgery; Group II (n = 202) was the control group. Patients were followed for a month after surgery. All mediastinal, sternal, pulmonary and cutaneous infections were documented and treated with appropriate antibiotics. A Student test for quantitative data and a chi2 test for qualitative data were used for statistical analysis. p < or = 0.05 was considered significant. RESULTS: The two groups had the same demographic characteristics and risk factors. Nasal carriage of Staphylococcus was 36.2% in the two groups. Neither mediastinitis nor sternitis were noticed in any of the two groups. There was no statistical difference between the groups according to the frequency of the cutaneous infections (Group I: 19/190 - Group II: 13/202) and pneumonia (Group I: 7/190 - Group II: 13/202). In patients who had nasal carriage of Staphylococcus, nasal decontamination has not shown a statistical difference of cutaneous infections of the lower limbs nor pneumonia. Although nasal decontamination reduced the incidence of sternal wound infection (Gr I 0/190 - Gr II 4/202 ; p = 0.017). Staphylococcus aureus, in the control group, induced more cutaneous infections (30.8% vs 11.7% ; p = 0.048). CONCLUSION: The usage of mupirocin for nasal decontamination before open-heart surgery reduces the incidence of the sternal wound infection, and does not seem to affect the frequency of cutaneous infections of the lower limbs nor pneumonia after this surgery.

Acute thrombosis of abdominal aortic aneurysm during cardiac surgery.

Aortic thrombosis has been described in the medical literature as a rare and catastrophic complication of abdominal aortic aneurysms. However, it has only been reported once in cardiac surgical settings. We report a unique case of thrombosis of an abdominal aortic aneurysms during the course of cardiac surgery, in a fully anticoagulated patient on cardiopulmonary bypass. Prompt diagnosis and immediate surgical management were critical for a successful outcome.