Surgical techniques in the management of supratentorial pediatric brain tumors: 10 years' experience at a tertiary care center in the Middle East.

BACKGROUND: The goal of this retrospective study is to present the first epidemiological data on pediatric supratentorial central nervous system (CNS) tumors in Lebanon and to review the various surgical management strategies used. METHODS: We conducted a retrospective case series of all pediatric patients who presented with a supratentorial CNS tumor and underwent surgery at our institution between 2006 and 2016. We collected and analyzed demographic characteristics, tumor location, clinical manifestations, histopathology, and surgical management strategies and outcome, and discussed them after dividing the tumors as per location and in view of published literature. RESULTS: Ninety-nine children were studied with a male-to-female ratio of 2.3:1 and a mean age of 8.5 years. The most common location was convexity (44%) and included low-grade and high-grade glial tumors, along with other miscellaneous lesions. The next location was sellar/diencephalic (34%), including craniopharyngiomas, hypothalamic/optic pathway/thalamic gliomas, hamartomas, and pituitary/Rathke's cyst, where there was notable use of endoscopic techniques (21%). Tumors in the pineal region (13%) were tectal gliomas, germ cell tumors, and pineoblastomas and were mostly treated endoscopically. The last group was lateral intraventricular tumors (8%) and was mostly choroid plexus lesions and ependymomas. Overall, the surgical objective was achieved in 95% with mild/moderate complications in 17%. CONCLUSION: A variety of pathologies may affect the pediatric population in the supratentorial region. Different surgical strategies, including microsurgical and endoscopic techniques, may be employed to remove, debulk, or biopsy these tumors depending on their location, suspected diagnosis, prognosis, and the need for treatment of possible associated hydrocephalus.

Outcomes following Craniosynostosis Surgery at a Tertiary Care Center in the Middle East.

BACKGROUND: Despite advancements in craniosynostosis surgery, open surgical approaches remain crucial for the management of infants >6 months of age and in those with complex synostosis. The clinical features of craniosynostosis remain poorly characterized in the Middle East. This study sought to assess the clinical features and outcomes of infants undergoing craniosynostosis surgery at a tertiary care center in Lebanon. METHODS: A retrospective review was performed of all patients who underwent craniosynostosis surgery from December 2006 to December 2018 at the American University of Beirut Medical Center, Lebanon. Clinicodemographic characteristics, complications, and recurrence outcomes were recorded and evaluated using descriptive statistics. RESULTS: Thirty-five infants met the inclusion criteria, with a mean age of 9.0 ± 4.0 months. The most common site of suture involvement was metopic (28.6%), followed by unilateral coronal (25.7%), sagittal (20.0%), bicoronal (8.6%), and multiple sites (17.1%). Five patients (14.3%) had syndromic synostosis. Median estimated blood loss was 200 mL, and median volume of transfused packed red blood cells was 180 mL. Two patients (5.7%) experienced postoperative complications, including postoperative blood transfusion (n = 1)and wire protrusion requiring removal (n = 1). Three patients (8.6%) required reoperation: 2 (5.7%) for resynostosis and 1 for traumatic fracture repair. Caregivers of all patients reported high satisfaction with cosmetic outcomes 4 weeks postoperatively. CONCLUSIONS: With appropriate perioperative precautions, open craniosynostosis surgery can be performed with minimal complications, low recurrence rates, and satisfactory cosmetic outcomes. Additional population-level data are needed to better characterize craniosynostosis patterns and outcomes in the Middle East.

Ultrasound-Guided Quadratus Lumborum Block for Postoperative Pain in Abdominoplasty: A Randomized Controlled Study.

BACKGROUND: Postoperative pain after abdominoplasty can delay postoperative ambulation, leading to life-threatening complications. Previous reports have shown the utility of quadratus lumborum block in providing adequate pain relief and avoiding side effects after numerous abdominal operations. The purpose of this randomized controlled trial was to demonstrate the efficacy of the quadratus lumborum block in abdominoplasty. METHODS: Patients were randomly allocated to receive a bilateral quadratus lumborum block with either ropivacaine or normal saline. Postoperative cumulative analgesic medication consumption, pain severity at rest and on movement, and quality of recovery were evaluated and compared in both groups. RESULTS: Twenty patients were allocated to each group. Total morphine dose received in the postanesthesia care unit was lower in the ropivacaine group than in the control group, with a mean of 3.4 mg and 6.6 mg, respectively. Cumulative tramadol consumption per patient in the first 48 hours postoperatively was significantly lower in the ropivacaine group compared with the control group (42.5 mg versus 190 mg; p = 0.0031). The Numeric Rating Scale both at rest and with effort was significantly lower in the ropivacaine group compared with the control group. The median quality of recovery for the ropivacaine group was 133 compared with 112 for the control group (p < 0.0001). CONCLUSIONS: Quadratus lumborum block in abdominoplasty reduces postoperative pain and opioid consumption and improves the quality of recovery. Further studies are needed to compare the quadratus lumborum block to more traditional blocks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Salvage therapy for vagal nerve stimulator infection; Literature review and report of a delayed recurrence.

BACKGROUND: Vagal Nerve Stimulation (VNS) is one of the most common neuro-modulation based approaches for the treatment of medically intractable epilepsy. Despite advances in technology and surgical techniques, hardware infection remains a recognized and feared complication in VNS placement. Management of such infections is scarce in the literature with the majority of data available in case reports. It ranges from immediate removal of the VNS device to conservative treatment with antibiotics in an attempt to salvage the device, particularly in patients who demonstrated significant improvement in seizure frequency and quality of life. METHODS: We performed a review of the literature in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify reported cases of salvaged VNS infection. A literature search for relevant English articles was conducted using Medline. References of relevant articles were also reviewed. Articles that comprised an attempt to salvage an infected VNS were included. RESULTS: We obtained 12 articles describing an attempt to salvage an infected VNS. Out of a total of 62 reported VNS infections and 43 salvage attempts using a variety of antibiotic-based approaches, 17 cases were successfully salvaged and 26 cases failed the salvage attempt and had to be explanted eventually. Moreover, we report a case of an 18-year-old male with Lennox-Gastaut syndrome who presented21 days after VNS placement with a MRSA deep tissue infection. An attempt was made to treat the infection with long-term culture-based intravenous antibiotics, but it recurred three years later with neck wound dehiscence and positive wound culture for the same organism, and ex-plantation was thus performed. CONCLUSION: The management of VNS infections remains a dilemma for neurosurgeons. Although the idea of salvaging an infected VNS seems appealing, hardware removal seems to be inevitable despite adequate antibiotic treatment.

Correlation of genetic alterations by whole-exome sequencing with clinical outcomes of glioblastoma patients from the Lebanese population.

INTRODUCTION: Glioblastoma (GBM) is an aggressive brain tumor associated with high degree of resistance to treatment. Given its heterogeneity, it is important to understand the molecular landscape of this tumor for the development of more effective therapies. Because of the different genetic profiles of patients with GBM, we sought to identify genetic variants in Lebanese patients with GBM (LEB-GBM) and compare our findings to those in the Cancer Genome Atlas (TCGA). METHODS: We performed whole exome sequencing (WES) to identify somatic variants in a cohort of 60 patient-derived GBM samples. We focused our analysis on 50 commonly mutated GBM candidate genes and compared mutation signatures between our population and publicly available GBM data from TCGA. We also cross-tabulated biological covariates to assess for associations with overall survival, time to recurrence and follow-up duration. RESULTS: We included 60 patient-derived GBM samples from 37 males and 23 females, with age ranging from 3 to 80 years (mean and median age at diagnosis were 51 and 56, respectively). Recurrent tumor formation was present in 94.8% of patients (n = 55/58). After filtering, we identified 360 somatic variants from 60 GBM patient samples. After filtering, we identified 360 somatic variants from 60 GBM patient samples. Most frequently mutated genes in our samples included ATRX, PCDHX11, PTEN, TP53, NF1, EGFR, PIK3CA, and SCN9A. Mutations in NLRP5 were associated with decreased overall survival among the Lebanese GBM cohort (p = 0.002). Mutations in NLRP5 were associated with decreased overall survival among the Lebanese GBM cohort (p = 0.002). EGFR and NF1 mutations were associated with the frontal lobe and temporal lobe in our LEB-GBM cohort, respectively. CONCLUSIONS: Our WES analysis confirmed the similarity in mutation signature of the LEB-GBM population with TCGA cohorts. It showed that 1 out of the 50 commonly GBM candidate gene mutations is associated with decreased overall survival among the Lebanese cohort. This study also highlights the need for studies with larger sample sizes to inform clinicians for better prognostication and management of Lebanese patients with GBM.

Nontuberculous Mycobacterial Infections After Cosmetic Procedures: A Systematic Review and Management Algorithm.

BACKGROUND: Nontuberculous mycobacterium (NTM) infection following cosmetic procedures usually results from inadequate sterile techniques and contamination from nonsterile water. These infections are difficult to diagnose and treat. OBJECTIVE: This study aimed to describe the characteristics of NTM infections acquired after an aesthetic procedure, identify high-risk patients and high-risk cosmetic procedures, and provide a diagnostic and management algorithm for NTM infections occurring after cosmetic procedures. METHODS: On December 20, 2017 an online search of the Medline database was done. All articles describing NTM infection in cosmetic procedures were included in this review. RESULTS: In total, 92 patients with a mean age of 38.35 years were included in this review. Cosmetic procedures performed in the Dominican Republic were the most common source of infection and were noted in 33 patients. The procedure that resulted in the highest proportion of the infections was mesotherapy (34%). In most of the cases, the diagnosis was missed at the initial presentation and a short course of inadequate antibiotics was unsuccessful. CONCLUSION: Nontuberculous mycobacterium infections are hard to diagnose and difficult to treat, sometimes leading to severe irreversible sequalae. Aesthetic practitioners should know when to suspect and how to prevent, diagnose, and treat NTM infections.

The Impact of Upper Face Botulinum Toxin Injections on Eyebrow Height and Forehead Lines: A Randomized Controlled Trial and an Algorithmic Approach to Forehead Injection.

No previous study has objectively evaluated the effect of different forehead injection patterns on the eyebrow height and forehead lines. The patients were divided into three groups. Botulinum toxin was injected into both the lateral and medial eyebrow depressors in all groups. The frontalis was injected using either a V-pattern (group 1), a middle horizontal pattern (group 2), or a high horizontal pattern (group 3). Objective eyebrow measurements were performed using standardized preinjection and postinjection photographs. Validated photonumeric scales were used to assess the forehead lines. Fifteen patients (30 eyebrows) were included in each group. In all of the groups, 2 weeks after injection, the brow was lower at all the measured positions, with the exception of the lateral brow edge, which was higher in the three injection patterns. No difference was found when comparing group 1 to groups 2 and 3. The middle forehead injection pattern lowered the eyebrow more than the upper forehead injection pattern. The three techniques improved the forehead lines at rest and with contraction. The forehead lines with contraction were more improved in group 1 compared with both groups 2 and 3. Each forehead injection pattern yielded different results on forehead lines and eyebrow position. Upper forehead injections were less effective on forehead lines but prevented eyebrow ptosis. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, II.

Evaluation of the Microbotox Technique: An Algorithmic Approach for Lower Face and Neck Rejuvenation and a Crossover Clinical Trial.

BACKGROUND: Microbotox consists of the injection of microdroplets of botulinum toxin into the dermis to improve the different lower face and neck aging components. No clinical trial has evaluated its effect on the different face and neck components and no study has compared it to the "Nefertiti lift" procedure. METHODS: In this crossover study, patients previously treated with the Nefertiti lift were injected using the microbotox technique. Using standardized preinjection and postinjection photographs, the jowls, marionette lines, oral commissures, neck volume, and platysmal bands at maximal contraction and at rest were assessed with validated photonumeric scales. In addition, the overall appearance of the lower face and neck was evaluated by the Investigators and Subjects Global Aesthetic Improvement Score. Pain and patient satisfaction rates were also evaluated. RESULTS: Twenty-five of the 30 patients previously treated with the Nefertiti technique were injected with a mean dose of 154 U using the microbotox technique. Platysmal bands with contraction, jowls, and neck volume reached a statistically significant improvement. The microbotox technique improved the jowls and the neck volume more than the Nefertiti technique, whereas the platysmal bands at rest and with contraction were more improved by the Nefertiti technique. One hundred percent of patients were satisfied with both techniques and rated themselves as improved. CONCLUSIONS: The microbotox technique is a useful, simple, and safe procedure for lower face and neck rejuvenation. It is mainly effective in treating neck and lower face soft-tissue ptosis, in contrast to the Nefertiti technique, which is more effective on platysmal bands. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Impact of Botulinum Toxin on Brow Height and Morphology: A Randomized Controlled Trial.

BACKGROUND: Previous reports have objectively demonstrated the efficacy of botulinum toxin for brow elevation. No clinical trial has compared the variation of the eyebrow shape and height when the lateral eyebrow depressors are injected alone or in combination with the medial eyebrow depressors. METHODS: A prospective, randomized, controlled study was designed to evaluate and compare the effect of two different botulinum toxin injection techniques on brow shape and position. Patients were divided into two groups. AbobotulinumtoxinA was injected in the lateral eyebrow depressors alone (group 1) or in both the lateral and medial eyebrow depressors (group 2). Objective eyebrow measurements were performed using standardized preinjection and postinjection photographs. Patient satisfaction was also evaluated. RESULTS: Fifteen patients (30 eyebrows) were included in each group. The brow elevated by 0.6 to 2.1 mm at all positions in group 1. In group 2, the brow elevated from the medial limbus to the lateral edge of the brow (1 to 1.7 mm), with no changes at the level of the medial brow and canthus. When comparing the two injection techniques, the authors found a statistically significant difference in the change of eyebrow height at the level of the medial brow, medial canthus, and lateral brow edge. Ninety-seven percent of patients were satisfied with their results. CONCLUSION: Different eyebrow injection techniques yield different elevation patterns. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Anaplastic Meningioma Presenting as a Left Parietal Mass: A Case Report.

BACKGROUND Meningiomas are slow-growing tumors attached to the dura mater and are composed of neoplastic meningothelial cells. The tumors are most commonly located in convexities, and it is relatively rare to find such a growth in the parietal region such as the one presented in this case report. CASE REPORT Because of its uncommon presentation, we hereby report the case of a 67-year-old, previously healthy, white Lebanese female patient who presented with forgetfulness, unsteady gait, right-sided motor weakness, and dysphagia. She was found to have an anaplastic meningioma located in the left parietal lobe that was treated by surgical resection. The patient had an uneventful postoperative course, and was stable at later follow-ups. CONCLUSIONS This case report describes the clinical presentation, pathological findings, and the prognosis of this mass, which is atypical in this location, and has been rarely reported in the literature. We also review the literature on anaplastic meningiomas.

Botulinum Toxin for Neck Rejuvenation: Assessing Efficacy and Redefining Patient Selection.

BACKGROUND: The "Nefertiti lift" consists of injecting the platysmal bands and the inferior border of the mandible with botulinum toxin. No clinical trial has evaluated its effect on the different lower face and neck aging components, and little is known about the clinical characteristics that predict treatment success. METHODS: Patients were injected with abobotulinumtoxinA along the inferior border of the mandible and into the platysmal bands. Using standardized preinjection and postinjection photographs, the jowls, marionette lines, oral commissures, neck volume, and platysmal bands at maximal contraction and at rest were assessed with validated photonumeric scales. In addition, the overall appearance of the lower face and neck was evaluated by the Investigators and Subjects Global Aesthetic Improvement Score. Pain and patient satisfaction rates were also evaluated. RESULTS: Thirty patients were injected with a mean dose of 124.9 U of abobotulinumtoxinA per patient. Platysmal bands at rest and with maximal tension reached a statistically significant improvement. The other components showed a tendency for improvement but did not reach statistical significance; 93.3 percent of investigators and patients rated the overall results as improved, and 96.6 percent of patients were satisfied with their results. When comparing the patients who improved the most to all the other patients, they had lower preinjection region-specific scores. CONCLUSIONS: The Nefertiti lift can be used on its own or in conjunction with other rejuvenating procedures. It is particularly helpful in younger patients with platysma muscle hyperactivity and retained skin elasticity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Comparison of microwave ablation, botulinum toxin injection, and liposuction-curettage in the treatment of axillary hyperhidrosis: A systematic review.

BACKGROUND: Primary focal axillary hyperhidrosis is a disorder of excessive sweating that can strongly impact quality of life. OBJECTIVE: The objective if this study was to compare microwave ablation (MA), botulinum toxin (BT) injection, and liposuction-curettage (LC) in the treatment of primary axillary hyperhidrosis based on subjective and objective criteria. METHODS: A systematic review of the literature published in French or English between 1 January 1991 and 1 February 2015 was completed using PubMed and Embase databases. RESULTS: 16 of 775 articles were selected based on relevance and criteria of inclusion and exclusion. The three methods proved to be efficient and safe; however, MA and BT had better results when compared to LC in the short term. Both MA and LC showed longer lasting results when compared to BT. However, in the long term, MA was superior to LC. CONCLUSION: MA, LC, and BT injections are safe and efficient minimally invasive alternatives for the treatment of axillary hyperhidrosis. Well-designed randomized controlled trials are needed to further compare the efficacy of these techniques.

Effect of Tissue Adhesives on Seroma Incidence After Abdominoplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Tissue adhesives (TAs) are widely utilized in abdominoplasty to reduce postoperative seroma. However, current literature regarding TAs in abdominoplasty is limited to small studies and the findings of single institutions. OBJECTIVES: The authors reviewed the current literature regarding the effects of TAs on seroma formation and other endpoints following abdominoplasty, and summarized the types of TAs and application techniques that have been described to date. METHODS: A systematic review of the Medline, Embase, Web of Science, and Cochrane databases was conducted to identify randomized controlled trials (RCTs) in which the numbers of patients who experienced seroma after abdominoplasty were indicated. The Cochrane Collaboration's tool for assessing risk of bias was applied. RESULTS: Seven studies were included in a descriptive review, 5 of which were RCTs. Data from the 5 RCTs were pooled for a meta-analysis. Patients who received TAs following abdominoplasty had a similar incidence of seroma compared with patients who did not receive TAs. However, the total drainage volume was significantly lower for patients who received TAs. CONCLUSIONS: There is a paucity of high-quality evidence to support the delivery of TAs to prevent seroma formation after abdominoplasty. Well-designed RCTs are needed to assess with confidence the overall effects of TAs in abdominoplasty. LEVEL OF EVIDENCE: 2 Therapeutic.

Botulinum Toxin for the Treatment of Excessive Gingival Display: A Systematic Review.

BACKGROUND: To date, no standardized minimally invasive approach for the treatment of excessive gingival display exists. OBJECTIVES: This systematic review aims to assess the evidence in the literature regarding the role of botulinum toxin injection in the management of gummy smile. METHODS: All publications through December 2014 and pertaining to the subject were electronically searched in PubMed, Embase, Scopus, and Web of Science, and the bibliographies of retrieved articles were manually screened. RESULTS: Out of 33 articles, 29 were discarded based on exclusion criteria. Although all 4 selected articles were in line with a role for botulinum toxin injection in the treatment of gummy smiles and the importance of targeting the levator labii superioris alaeque nasi muscle, studies differed in the type and the dose of toxin administered and the technique adopted. CONCLUSIONS: Injection with botulinum toxin is a novel, safe, and cosmetically effective treatment for gummy smile when performed by experienced practitioners. However, further randomized controlled trials are warranted. LEVEL OF EVIDENCE 4: Therapeutic.

Synthesis, conformational stability, and asymmetric transformation of atropisomeric 1,8-bisphenolnaphthalenes.

Highly congested, axially chiral 1,8-bisphenolnaphthalenes have been synthesized in 75% overall yield by palladium-catalyzed Suzuki coupling of 1,8-diiodonaphthalene and 4-methoxy-2-methylphenylboronic acid followed by regioselective formylation and deprotection. The C(2)-symmetric anti-stereoisomers of 1,8-bis(2'-methyl-4'-hydroxy-5'-formylphenyl)naphthalene, 5, and its diimine analogues 9 and 10 were found to be significantly more stable than the corresponding syn-isomer. Crystallographic analysis revealed that this stereochemical preference results from a unique intramolecular hydrogen bonding motif and concomitant minimization of steric repulsion. Triaryl 5 proved stable to rotation about the chiral axes at room temperature and the enantiomers were isolated via formation of diastereomeric diimines with (R)-2-amino-1-propanol and (R)-2-amino-3-methyl-1-butanol, respectively, chromatographic separation, and mild hydrolysis. Slow syn/anti-interconversion of 5, 9, and 10 was observed at enhanced temperatures and the diastereomerization and enantiomerization processes were monitored by CD and NMR spectroscopy. The Gibbs activation energy, ΔG(‡), for the isomerization of 5 was determined as 103.7 (102.4) kJ/mol for the conversion of the anti-(syn-) to the syn-(anti-)isomer at 45.0 °C. Condensation of 5 with two chiral amino alcohols generates diimines that undergo quantitative asymmetric transformation of the first kind toward the thermodynamically favored (P,P,R,R)- or (M,M,S,S)-atropisomer, respectively. The incorporation of two imino alcohol units controls the outcome of this unidirectional atropisomerization, i.e. the central chirality of the amino alcohol used induces a rigid, axially chiral triaryl scaffold with perfect stereocontrol. Accordingly, the rotational energy barrier for the conversion of (M,M,S,S)-9 to its syn-isomer is significantly increased and was determined as 115.7 kJ/mol at 58.0 °C.

Stereocontrolled photodimerization with congested 1,8-bis(4'-anilino)naphthalene templates.

Suzuki cross-coupling of a 1,8-dihalonaphthalene with 4-methoxy-3-methylphenylboronic acid or 4-acetamidophenylboronic acid and subsequent functional group transformation gave 1,8-bis(3'-methyl-4'-anilino)naphthalene, 16, and 1,8-bis(4'-anilino)naphthalene, 21, in 65% and 90% overall yield, respectively. These congested compounds exhibit two cofacial aniline rings that favor a proximate, parallel arrangement of covalently attached cinnamoyl units suitable for stereoselective photodimerization. The [2 + 2]cycloaddition was found to proceed with high yield and exclusive formation of cis,trans,cis-cyclobutane-1,2-dicarboxylic acids. Amide formation with cinnamoyl chloride and template 21 followed by photochemical dimerization and acidic hydrolysis gave ß-truxinic acid, 10, in 69% overall yield. Coupling of 21 and (E)-3-(3,4-dimethylphenyl)acrylic acid in the presence of EDC, UV irradiation, and cleavage gave cis,trans,cis-3,4-bis(3,4-dimethylphenyl)cyclobutane-1,2-dicarboxylic acid, 26, in 60% yield. In both cases, the template was quantitatively recovered.

Evaluation of intractable epilepsy. Invasive monitoring.

Accurate localization of the epileptogenic zone is the fundamental key factor for successful epilepsy surgery. Despite the progress achieved in the field of neuroimaging, invasive intracranial recording is still the gold standard that helps recognize the patient population who may profit from surgery. Meticulous implantation of intracranial electrodes and judicious interpretation of their data is a definite need in a successful epilepsy program. Few centers in the Arab world are in that domain. Moreover, the society itself is not well informed to appreciate the potentials of surgical treatment of seizure disorders. In this review article, we will go over various types of intracranial recordings, discussing their indications, and the last updates for each. Some of the cases carried out at the American University of Beirut Medical Center, Beirut, Lebanon will be illustrated as examples of our current practice. Then, the future of epilepsy monitoring will be highlighted in brief.