Case report: A vertebral bone spur as an etiology for spinal cord herniation: case presentation, surgical technique, and review of the literature.

Objective: The pathophysiology of idiopathic spinal cord herniation remains unknown. However, several different factors have been postulated, such as congenital causes (ventral dura mater duplication, preexisting pseudomeningocele, or other congenital dural defects), inflammation, remote spinal trauma, or thoracic disc herniation. Herein, the diagnosis and surgical treatment of a patient with spinal cord herniation caused by an intraspinal bone spur is presented along with a relevant literature review. Case presentation: A 56-year-old male patient presented with a non-traumatic Brown-Sequard syndrome persisting for over 1 year. A magnetic resonance imaging of the spinal axis revealed a ventral spinal cord displacement in the level of T 6/7. A supplementary thin-sliced computed tomography of the spine revealed a bone spur at the same level. For neurosurgical intervention, T 6 and T 7 laminectomy was performed. The cranial and caudal end of the right paramedian ventral dural defect was visualized and enlarged. Following extradural spinal cord mobilization by denticulate ligament transection, the spinal cord was finally released. The spinal cord was rotated and the ventral closure of the dural defect was performed by continuous suture. The patient recovered from surgery without additional deficits. The patient's postoperative gait, sensory, and motor function deficits improved, and further neurological deterioration was prevented. Conclusion: Since the first description of spinal cord herniation by Wortzman et al. in 1974, approximately 260 cases have been reported in the literature. In addition to other causes, intraspinal bone spur is a possible cause of spinal cord herniation.

Case report: Interdisciplinary treatment of complex C1/C2 fractures in a patient with concomitant three-vessel coronary artery disease requiring bypass surgery.

Background: Acute myocardial infarction (MI) frequently leads to consciousness disturbance following hemodynamic collapse. Therefore, MI can occur together with upper cervical spine trauma. Herein, we report the successful treatment of complex C1/C2 fractures in a patient with concomitant three-vessel coronary artery disease (CAD). Case presentation: A 70-year-old patient presented in our emergency outpatient clinic after a hemodynamic collapse without neurological deficits or heart-related complaints. Computed tomography (CT) scan of the cervical spine revealed a dislocated odontoid fracture Anderson and D'Alonzo type II and an unstable Gehweiler type III injury (Jefferson's fracture). An intradiploic arachnoid cyst in the posterior wall of the posterior fossa was a coincident radiological finding. Furthermore, coronary angiography confirmed three-vessel CAD with high-grade coronary artery stenosis. Indication for upper cervical spine surgery and bypass surgery was given. An interdisciplinary team of neurosurgeons, cardiothoracic surgeons and anesthesiologists evaluated the patient's case to develop the most suitable therapy concept and alternative strategies. Finally, in first step, C1-C2 fusion was performed by Harms technique under general anesthesia with x-ray guidance, spinal neuronavigation, Doppler ultrasound and cardiopulmonary monitoring. Cardiothoracic surgeons were on standby. One month later bypass surgery was performed uneventfully. Follow-up CT scan of cervical spine revealed intraosseous screw positioning and beginning fusion of the fractures. The patient did not develop neurological deficits and recovered completely from both surgeries. Conclusions: Treating complex C1/C2 fractures with concomitant severe CAD requiring treatment is challenging and carries a high risk of complications. To our knowledge, the literature does not provide any guidelines regarding therapy of this constellation. To receive upper cervical spine stability and to prevent both, spinal cord injury and cardiovascular complications, an individual approach is required. Interdisciplinary cooperation to determine optimal therapeutic algorithms is needed.

Surgical management of choroid plexus papilloma of the cerebellopontine and cerebellomedullary angle: classification and strategy.

Choroid plexus papillomas (CPPs) are primary neuroectodermal neoplasms that usually arise in the fourth ventricle in adults. In this study, we present 12 patients with CPP arising from the cerebellopontine angle (CPP-CPA) and/or of the cerebellomedullary angle (CPP-CMA) that were treated in our department. Patients who underwent surgery for the treatment for CPP-CPA/CMA from January 2004 to March 2020 were identified by a computer search of their files from the Department of Neurosurgery, Tübingen. CPPs were classified according to their location into type 1 (tumor portion only in the CPA,), type 2 (tumor portions only in the CMA), and type 3 (tumor portions both in the CPA and CMA). Patients were evaluated for initial symptoms, previous therapies in other hospitals, extent of tumor resection, recurrence rate, and complications by reviewing patient documents. Of approximately 1500 CPA lesions, which were surgically treated in our department in the last 16 years, 12 patients (mean age 42 ± 19 years) were found to have CPP-CPA/CMA. Five were male, and seven were female patients. Gross total resection was achieved in nine cases, and a subtotal resection was attained in three cases. Tumor recurrence in the same location after the first surgery in our hospital was observed in 2 patients after 15 and 40 months of follow-up, and in another patient, distant metastases (C3/4 and L3 levels) were observed. Surgical removal of CPP is the treatment of choice, but additional therapeutic options may be necessary in case of remnant tumor portions, recurrence, or malignant transformation.

Estimating the prevalence of autism spectrum disorder in Lebanon.

This cross-sectional survey examines the prevalence rate of Autism spectrum disorder (ASD) in 818 children (16-48 months) across all Lebanese regions. Screening was done using the revised form of the Modified-Checklist for Autism in Toddlers. Based on the total score of items failed, children were classified into 3 categories of ASD risk (low, moderate and high). Phone calls follow-up interviews and clinical assessments for diagnosis ascertainment were conducted. Given the caregivers' reluctance to participate, the prevalence rate was estimated between 49 and 513 per 10,000 with a male predominance. Our prevalence estimation, even under restrictive assumptions, is higher than elsewhere in the Arab region. Anti- stigma interventions adapted to the socio-cultural context are needed prior to future research in the field.

Is menarche occuring earlier among Lebanese girls?

BACKGROUND: Early menarche is associated with increased risks for several diseases such as cardiovascular diseases and breast cancer. This analysis aimed at generating evidence on a historical trend towards younger age at menarche among Lebanese girls. METHODS: A secondary analysis was conducted on data consolidated from three serial cross-sectional national surveys of women in Lebanon (2007, 2009 and 2012). A total of 6150 women were included in order to study the association between date of birth intervals and age at menarche. RESULTS: The mean age at menarche was 13.06 years, with a peak of the distribution at age 12. Women born before 1950 had a significantly higher mean age at menarche (13.21) compared to those born in 1970 and thereafter (12.95). A stratified analysis showed that women living outside the metropolitan Greater Beirut (GB) area were characterized by an older mean age at menarche (13.11) in all date of birth intervals compared to those in GB (12.89). However, age at menarche declined more significantly over the last two decades among women outside GB, compared to those living in GB. CONCLUSIONS: Epidemiological figures emerging from this study confirm that trends in Lebanon are in line with a global pattern of decreasing age at menarche. Urban-rural differences suggest that higher caloric content of diet and consequent early overweight, more evident in urban areas, are likely determinants of younger menarche. Evidence from this study calls for an urgent implementation of comprehensive multisectoral obesity prevention in children in Lebanon.

Paradigm-shift: radiological changes in the asymptomatic iNPH-patient to be: an observational study.

BACKGROUND: Many radiological signs are known for the diagnosis of idiopathic normal pressure hydrocephalus (iNPH). However, there is little information about these signs in the pre-symptomatic phase. For pathophysiological investigative purposes we conducted a descriptive image analysis study on pre-symptomatic patients. METHODS: Patients that had contact with either the neurological or neurosurgical department of the university hospital Tuebingen from 2010 through 2016 with magnetic resonance images > 3 years before onset of symptoms, were included. The date of onset and severity of symptoms, date of first imaging and birth date were recorded. Evan's index (EI), width of the third ventricle (3VW), tight high convexity (THC), Sylvian fissure, extent of white matter hyperintensities and aqueductal flow were assessed in images before and around symptom onset. RESULTS: Ten patients were included. In all ten patients the first symptom was gait disturbance. Nine of ten pre-symptomatic images showed classic signs for iNPH. EI showed a significant increase between the pre-symptomatic and symptomatic phase. 3VW showed a trend for increase without significance. THC changed back and forth over time within some patients. CONCLUSIONS: In accordance with the scarce literature available, radiological changes are present at least 3 years before onset of iNPH-symptoms. EI seems to be a robust measure for pre-symptomatic radiological changes. Extrapolating the data, the development of iNPH typical changes might be an insidious process and the development of THC might be a variable and non-linear process. Further studies with larger sample sizes are necessary to put these findings into the pathophysiological perspective for the development of iNPH.

Evaluation of Apoptotic Markers and Tissue Histology Indicate a Slight Advantage of Slow Freezing Method over Vitrification for Sheep Ovarian Tissues.

BACKGROUND: An efficient cryopreservation method is very important for preserving the fertility of sheep ovarian tissues. OBJECTIVE: To compare the slow freezing method and vitrification for cryopreservation of sheep ovarian tissues. METHODS: Dissected cortex fragments from ten sheep ovaries were used for the comparative study. Cryopreserved and control tissues were cultured for 24h and then evaluated according to follicular morphology and apoptotic assessment. RESULTS: In both slow freezing and vitrification methods, normal follicles were reduced when compared to the non-frozen control group. There were significantly more abnormal follicles with vitrification than with slow freezing method (P < 0.05). However, there were no significant differences with regard to apoptotic gene expression or the percentage of Caspase3 positive follicles among cryopreserved and control groups. CONCLUSION: A slight advantage of the slow freezing method was observed over vitrification for cryopreservation of sheep ovarian tissue fragments.

Cervical cancer screening among Lebanese women.

BACKGROUND: Cervical cancer is a very common malignancy amongst women worldwide. Pap smear is an effective and inexpensive screening test in asymptomatic women. The aim of this paper was to assess the prevalence of Pap smear screening for cervical cancer among Lebanese women and to determine associated sociodemographic and psychosocial characteristics. METHODS: This national survey included 2255 women, selected by multi-stage random cluster sampling across Lebanon. A questionnaire about practices and perceptions related to cervical cancer screening was developed based on the "Health Belief Model". RESULTS: The weighted national prevalence of "ever-use" of the Pap smear for screening purposes was 35%. Most important determinants of screening behavior were: residence within Greater Beirut, higher socio-economic status and educational attainment, marriage status, presence of a health coverage, awareness of Pap smear usefulness, knowing someone who had already done it, and a balance between perceived benefits and perceived barriers to Pap smear screening. CONCLUSION: Regular information campaigns regarding the availability and effectiveness of the test should be devised, targeting in priority the sexually vulnerable women in Lebanon. Moreover, healthcare providers should be encouraged to discuss with their patients the opportunity of obtaining a Pap smear.

Study of tonotopic brain changes with functional MRI and FDG-PET in a patient with unilateral objective cochlear tinnitus.

We studied possible brain changes with functional MRI (fMRI) and fluorodeoxyglucose positron emission tomography (FDG-PET) in a patient with a rare, high-intensity "objective tinnitus" (high-level SOAEs) in the left ear of 10 years duration, with no associated hearing loss. This is the first case of objective cochlear tinnitus to be investigated with functional neuroimaging. The objective cochlear tinnitus was measured by Spontaneous Otoacoustic Emissions (SOAE) equipment (frequency 9689 Hz, intensity 57 dB SPL) and is clearly audible to anyone standing near the patient. Functional modifications in primary auditory areas and other brain regions were evaluated using 3T and 7T fMRI and FDG-PET. In the fMRI evaluations, a saturation of the auditory cortex at the tinnitus frequency was observed, but the global cortical tonotopic organization remained intact when compared to the results of fMRI of healthy subjects. The FDG-PET showed no evidence of an increase or decrease of activity in the auditory cortices or in the limbic system as compared to normal subjects. In this patient with high-intensity objective cochlear tinnitus, fMRI and FDG-PET showed no significant brain reorganization in auditory areas and/or in the limbic system, as reported in the literature in patients with chronic subjective tinnitus.

Cost-benefit analysis: newborn screening for inborn errors of metabolism in Lebanon.

OBJECTIVES: Few countries in the Middle East-North Africa region have adopted national newborn screening for inborn errors of metabolism by tandem mass spectrometry (MS/MS). We aimed to evaluate the cost-benefit of newborn screening for such disorders in Lebanon, as a model for other developing countries in the region. METHODS: Average costs of expected care for inborn errors of metabolism cases as a group, between ages 0 and 18, early and late diagnosed, were calculated from 2007 to 2013. The monetary value of early detection using MS/MS was compared with that of clinical "late detection", including cost of diagnosis and hospitalizations. RESULTS: During this period, 126000 newborns were screened. Incidence of detected cases was 1/1482, which can be explained by high consanguinity rates in Lebanon. A reduction by half of direct cost of care, reaching on average 31,631 USD per detected case was shown. This difference more than covers the expense of starting a newborn screening programme. CONCLUSION: Although this model does not take into consideration the indirect benefits of the better quality of life of those screened early, it can be argued that direct and indirect costs saved through early detection of these disorders are important enough to justify universal publicly-funded screening, especially in developing countries with high consanguinity rates, as shown through this data from Lebanon.

[Interventional radiology procedures for malignancies of the liver treatment: Intraarterial procedures]. / Traitement des tumeurs maligne du foie par radiologie interventionnelle: techniques intra-artérielles.

Intraarterial procedures such as chemoembolization and radioembolization aim for the palliative treatment of advanced hepatocellular carcinoma (stage BCLC B and C with tumoral portal thrombosis). The combination of hepatic intraarterial chemotherapy and systemic chemotherapy can increase the probability of curing colorectal cancer with hepatic metastases not immediately accessible to surgical treatment or percutaneous ablation.

Detection of bleeding disorders in Lebanon: outcomes of a pilot programme.

To promote management and awareness of bleeding disorders in Lebanon, a pilot programme was launched in 2009 by the Lebanese Hemophilia Association assisted by World Federation of Hemophilia. The aim of this study was to diagnose patients with bleeding disorders and to assess the potential challenges in implementing a screening programme. The pilot project was launched in 26 social health centres in the Bekaa valley. The study tools included the evaluation of the Tossetto Bleeding Score and the Pictorial Bleeding Assessment Chart (PBAC) for menstruation. Persons with a bleeding score higher than 2 and PBAC higher than 185 were eligible for further blood tests including the prothrombin time, partial thromboplastin time, complete blood count, bleeding time and von Willebrand ristocetin cofactor activity. 643 patients were enrolled, of whom 60.6% were women. Overall, 91 persons had an abnormal score. 50 eligible patients were tested: 32 had normal tests, nine new patients with severe Von Willebrand were discovered, 4 had VW:RiCo of 40, 3 prolonged APTT and 2 thrombocytopaenia. There was a clear correlation between the severity of the score and the willingness to perform the tests (P = 0.02). Women were reluctant to participate fully when investigators were men. The probability of adherence to the screening protocol is significantly increased when directed by women health care professional. For patients with milder forms, global screening programmes were neither feasible nor acceptable but those more severely affected have to be identified. Providers are crucial in preselecting patients with blood problems who are not coping well.

Geographic epidemiology in a small area: cancer incidence in Baakline, Lebanon, 2000-2008.

Aggregate data of the National Clr cac gi s in Lebanon cannot discriminate cance r incidence i n small areas. Trained community members surveyed the permanent population of the Baakline municipality using the verbal autopsy approach. We surveyed 1042 households with at least 1 member living permanently in Baakline during 2000-2008. Data covered 4330 persons yielding 34,143 years of observation and 56 new cases of cancer were reported. Median age at diagnosis varied significantly between men (77 years) and women (56 years). The most common types were lung cancer (20%) followed by colorectal (12.5%) and breast (9%). Estimated crude cancer incidence rate was 164 cases/100,000 persons/year, significantly higher in men (194) than women (130), and much lower overall than the national figure (218). The permanent Baakline population is older than that of Lebanon itself, yet the cancer incidence rate is markedly lower than the national figure. This finding pleads for serious efforts to preserve the low environmental contamination and the healthy lifestyles in food and tobacco abstinence that have protected the population so far.

Geographic epidemiology in a small area: cancer incidence in Baakline, Lebanon, 2000-2008

Aggregate data of the National Cancer Registry in Lebanon cannot discriminate cancer incidence in small areas. Trained community members surveyed the permanent population of the Baakline municipality using the verbal autopsy approach. We surveyed 1042 households with at least 1 member living permanently In Baakline during 2000-2008. Data covered 4330 persons yielding 34143 years of observation and 56 new cases of cancer were reported. Median age at diagnosis varied significantly between men [77 years] and women [56 years]. The most common types were lung cancer [20%] followed by colorectal [12.5%] and breast [9%]. Estimated crude cancer incidence rate was164 cases/100 000 persons/year, significantly higher in men [194] than women [130], and much lower overall than the national figure [218]. The permanent Baakline population Is older than that of Lebanon itself, yet the cancer Incidence rate is markedly lower than the national figure. This finding pleads for serious efforts to preserve the low environmental | contamination and the healthy lifestyles In food and tobacco abstinence that have protected the population so far

Health-care-seeking behaviour among university students in Lebanon.

This cross-sectional study assessed the health-care-seeking behaviour, barriers to accessing care and associated factors among a sample of 543 Lebanese students at Saint-Joseph University. Data were collected on health-care-seeking behaviour for health issues in the previous 12 months using an anonymous questionnaire. Health-care-seeking behaviour was categorized as: formal (professional help sought); informal relational (help sought from friends/family); informal personal (self-help). The health issues examined were: physical, psychological, social and relational, sexual, drug, alcohol and smoking. When facing health-related issues, the students tended to seek informal health care. Formal health-care-seeking behaviour was almost non-existent for psychological issues (3.3%), relational and social issues (1.8%), and issues related to substance use (5.1%). The barriers to seeking formal health care fell into 2 categories: accessibility and relational. To encourage young people to access formal health care, specific health services should be provided for them where they are assured of confidentiality and understanding.

Characteristics of physicians practising in Lebanon: a survey.

The last survey of the characteristics of the Lebanese physician workforce, in 1998, raised concerns about the oversupply of physicians and gaps in capacity building. This telephone survey in 2007 of a stratified random sample of physicians describes the demographic, educational and practice characteristics of 546 physicians practising in Lebanon. A majority of the physicians had graduated from an eastern European or a Lebanese medical school, in the1980s or 1990s, and had postgraduate training in a non-primary care specialty, in a western or eastern European country. The greatest numbers were practising solo, in a medical or surgical specialty, in a private hospital and in an urban setting. The average proportion of work time spent in teaching and research were 2.4% and 1.2% respectively. The findings suggest that less emphasis should be placed on training in specialty care compared with primary care/general practice and future policies should aim to attract physicians to rural areas.

Physical and verbal/emotional abuse of schoolchildren, Lebanon, 2009.

The extent of physical and verbal/emotional abuse in schools in Lebanon is currently unknown. This cross-sectional study aimed to determine the prevalence and patterns of both forms of abuse among a nationally representative sample of Lebanese schoolchildren, aged 10-18 years, using a self-reported questionnaire. A total of 1177 schoolchildren, 49.6% females, median age 14 years, completed the survey; 76.4% and 81.2% of these had experienced physical and verbal/emotional abuse respectively at least once at school. Male students [adjusted odd ratio (AOR)= 3.4, P < 0.01], children in public schools (AOR = 1.9, P< 0.01) and in South Lebanon (AOR= 2.2, P < 0.01) and Bekaa (AOR = 1.7, P < 0.05) regions were more likely to have experienced physical abuse than females, children from private schools and from Beirut. Male students (AOR = 1.3, P < 0.01) and children in public schools (AOR = 1.6, P < 0.01) were also more likely to experience verbal abuse, with no regional differences. The prevalence of physical and verbal/emotional abuse in schools in Lebanon is high and solutions should be sought to correct the problem engaging political and social leaders, the mass media, law enforcement agencies, parents and educators.

Physical and verbal/emotional abuse of schoolchildren, Lebanon, 2009

The extent of physical and verbal/emotional abuse in schools in Lebanon is currently unknown. This cross-sectional study aimed to determine the prevalence and patterns of both forms of abuse among a nationally representative sample of Lebanese schoolchildren, aged 10-18 years, using a self-reported questionnaire. A total of 1177 schoolchildren, 49.6% females, median age 14 years, completed the survey; 76.4% and 81.2% of these had experienced physical and verbal/emotional abuse respectively at least once at school. Male students [adjusted odd ratio [AOR] = 3.4, P< 0.01], children in public schools [AOR = 1.9, P< 0.01] and in South Lebanon [AOR = 2.2, P< 0.01] and Bekaa [AOR = 1.7, P< 0.05] regions were more likely to have experienced physical abuse than females, children from private schools and from Beirut. Male students [AOR = 1.3, P< 0.01] and children in public schools [AOR = 1.6, P< 0.01] were also more likely to experience verbal abuse, with no regional differences. The prevalence of physical and verbal/emotional abuse in schools in Lebanon is high and solutions should be sought to correct the problem engaging political and social leaders, the mass media, law enforcement agencies, parents and educators

Characteristics of physicians practising in Lebanon: a survey

The last survey of the characteristics of the Lebanese physician workforce, in 1998, raised concerns about the oversupply of physicians and gaps in capacity building. This telephone survey in 2007 of a stratified random sample of physicians describes the demographic, educational and practice characteristics of 546 physicians practising in Lebanon. A majority of the physicians had graduated from an eastern Europe an or a Lebanese medical school, in the 1980s or 1990s, and had postgraduate training in a non-primary care specialty, in a western or eastern European country. The greatest numbers were practising solo, in a medical or surgical specialty, in a private hospital and in an urban setting. The average proportion of work time spent in teaching and research were 2.4% and 1.2% respectively. The findings suggest that less emphasis should be placed on training in specialty care compared with primary care/general practice and future policies should aim to attract physicians to rural areas