Impact of the 4th of August Beirut explosion mass casualty incident on a university hospital microbial Flora

BACKGROUND

Following the Beirut explosion, our university hospital received at least 350 casualties. Subsequently, infection control standard practices were compromised. Concerns for Multi-Drug Resistant Organisms (MDROs) infections in injured patients and a resulting hospital outbreak were raised. The objectives of the study were to compare the rate of hospital growing MDROs 6 months before and 6 months after the Beirut explosion, to identify emerging microorganisms and to evaluate the change in surgical infection prevention practices.

METHODS

This is a retrospective chart review of patients with hospital acquired infections (HAI) admitted to the hospital before and after the Beirut explosion. The study was conducted between February 4, 2020 and January 4, 2021. Excluded patients were those transferred from other hospitals and those with community acquired infections. The primary outcome was to identify the rate of growing MDROs post explosion. The secondary outcomes were identifying antibiotics used for surgical prophylaxis in patients requiring surgeries and patients diagnosed with a HAI. Therefore, patients were divided in three groups. Control group included patients admitted with explosion-related injuries on that same day. Patients admitted and between February 4 and August 4 and diagnosed with HAI were compared to those admitted post August 4 with explosion-related HAI and to patients diagnosed with non-explosion-related HAI between August 4 and January 4, 2021. An estimated rate of 18-22% MDRO was needed to achieve a statistical significance with 80% power and 0.05 α. Pearson Chi square test was used to analyze the primary outcome.

RESULTS

A total of 82 patients with 150 cultures were included in this study. Data showed an increase in the rate of MDRO after the explosion with 37.1% of the cultures taken before the explosion and 53.1% after the explosion (p = 0.05). When comparing the types of HAI in both groups, culture sites were significantly different between pre- and post-explosion patients (p = 0.013). However, both groups had similar types of microbes (p = 0.996) with an increase in candida related infections.

CONCLUSION

These findings confirmed that the Beirut explosion impact on antimicrobial resistance was similar to combat zone incidence, where an increase in MDROs rate such as Escherichia coli (E.Coli) and Stenotrophomonas maltophilia, in addition to the increase in candida related infections.

Maternal health outcomes in the context of fragility: a retrospective study from Lebanon

BACKGROUND AND AIMS

The Lebanese healthcare system faces multiple challenges including limited capacities, shortage of skilled professionals, and inadequate supplies, in addition to hosting a significant number of refugees. While subsidized services are available for pregnant women, representing the majority of the refugee population in Lebanon, suboptimal access to antenatal care (ANC) and increased maternal mortality rates are still observed, especially among socioeconomically disadvantaged populations. This study aimed to review the maternal health outcomes of disadvantaged Lebanese and refugee pregnant women seeking ANC services at primary healthcare centers (PHCs) in Lebanon.

METHODS

A retrospective chart review was conducted at twenty PHCs in Lebanon, including Ministry of Public Health (MOPH) and United Nations Relief and Works Agency for Palestine refugees (UNRWA) facilities. Data was collected from medical charts of pregnant women who visited the centers between August 2018 and August 2020. Statistical analysis was performed to explore outcomes such as the number of ANC visits, delivery type, and onset of delivery, using bivariate and multivariable logistic regression models.

RESULTS

In the study, 3977 medical charts were analyzed. A multivariate logistic regression analysis, revealed that suboptimal ANC visits were more common in the Beqaa region and among women with current abortion or C-section. Syrians had reduced odds of C-sections, and Beqaa, Mount Lebanon, and South Lebanon regions had reduced odds of abortion. Suboptimal ANC visits and history of C-section increased the odds of C-section and abortion in the current pregnancy. As for preterm onset, the study showed an increased likelihood for it to occur when being Palestinian, having current C-section delivery, experiencing previous preterm onset, and enduring complications at the time of delivery.

CONCLUSION

This study suggests the need for low-cost interventions aiming at enhancing access to ANC services, especially among pregnant women in fragile settings.

Assessment of mycotoxins in cornflakes marketed in Lebanon

Cornflakes are a popular and convenient breakfast cereal made from corn and widely consumed worldwide, including in Lebanon. However, they are susceptible to mycotoxin contamination, which can have harmful effects on human health. Our study evaluated the occurrence of five mycotoxins (AFB1, OTA, FUM, ZEA, DON) levels in packed cornflakes marketed in Lebanon. A market screening identified 35 different cornflake stock-keeping units (SKU) in the Lebanese market, originating from 10 different brands and having different tastes and shapes. SKUs were collected and tested for five mycotoxins in triplicates using enzyme-linked immunosorbent assay technique. The results showed the presence of the five mycotoxins in the samples. The average levels of AFB1, OTA, ZEA and FUM among positive samples (above limit of detection) were 1.58, 1.2, 15.1 and 774.1 μg/kg, respectively, and were below the EU limits. On the other hand, the average level of DON was 1206.7 μg/kg, exceeding the EU limit. Furthermore, out of the positive samples, 60%, 17%, 9%, 14%, and 6% exceeded the EU limits for DON, OTA, AFB1, FUM, and ZEA, respectively. Notably, SKUs made in Lebanon had significantly (p < 0.05) higher levels of AFB1 and FUM. The packing size of the cornflakes had no significant (p > 0.05) effect on the levels of the five mycotoxins detected in the samples. AFB1, FUM and ZEA levels differed significantly among SKUs (p > 0.05). Considering these findings, further studies should be conducted to assess the exposure to mycotoxins from the consumption of cornflakes in Lebanon, especially among children.

Lower odds of COVID-19-related mortality in hospitalised patients with type II diabetes mellitus: A single-centre study

BACKGROUND

COVID-19 infection in patients with type 2 diabetes mellitus (T2DM) -a chronic illness in Lebanon-is not well described.

METHODS

This was a single-centre retrospective observational study of 491 patients, including 152 patients with T2DM, who were hospitalised for COVID-19 between 20 August 2020 and 21 April 2021. Data on clinical characteristics, laboratory and radiological findings and outcomes were collected from the electronic medical records. Clinical characteristics and in-hospital mortality between patients with and without T2DM infected with COVID-19 using multivariate analysis were compared.

RESULTS

Patients with T2DM were significantly older than those without T2DM (mean age, 68.7 vs. 60.3 years). Patients with T2DM were more likely to present with a body temperature of <38.3°C (83.9% vs. 69.9%) and less likely to present with chest pain (3.9% vs. 9.1%) and sore throat (2.0% vs. 6.8%). Patients with T2DM were more likely to be hypertensive (76.35% vs. 41%) and dyslipidaemic (58.6% vs. 25.7%) and had more frequent underlying coronary artery disease (33.6% vs. 12.4%). The rates of patients with creatinine levels of ≥1.17 mg/L and troponin T levels of ≥4 ng/dL were higher in the T2DM group than in the non-T2DM group (30.4% vs. 15% and 93.3% vs. 83.1%, respectively). Patients with T2DM were more likely to be admitted to the intensive care unit (ICU) (34.2% vs. 22.1%), require invasive ventilation (18.4% vs. 10.3%) and receive vasopressors (16.4% vs. 10.0%). Increasing age and the use of invasive ventilation and vasopressors were associated with higher odds of mortality (odds ratio (OR), 1.08, 9.95 and 19.83, respectively), whereas longer ICU stay was associated with lower odds of mortality (OR, 0.38). The odds of mortality were lower in the T2DM group than in the non-T2DM group (OR, 0.27).

CONCLUSION

Among patients hospitalised for COVID-19, those with T2DM were older, presented with milder symptoms and had more comorbidities and higher troponin T levels compared with those without T2DM. Despite the worse clinical course, the patients with T2DM had lower odds of mortality than those without T2DM.

Aflatoxins and Ochratoxin A in Tea Sold in Lebanon: Effects of Type, Packaging, and Origin

Tea is among the oldest and most-known beverages around the world, and it has many flavors and types. Tea can be easily contaminated in any of its production steps, especially with mycotoxins that are produced particularly in humid and warm environments. This study aims to examine the level of ochratoxin A (OTA) and total aflatoxin (AF) contamination in black and green tea sold in Lebanon, evaluate its safety compared to international standards, and assess the effect of different variables on the levels of OTA and AFs. For this, the Lebanese market was screened and all tea brands (n = 37; 24 black and 13 green) were collected twice. The Enzyme-Linked Immunoassay (ELISA) method was used to determine OTA and AFs in the samples. AFs and OTA were detected in 28 (75.7%) and 31 (88.6%) samples, respectively. The average of AFs in the positive (above detection limit: 1.75 μg/kg) samples was 2.66 ± 0.15 μg/kg, while the average of OTA in the positive (above detection limit: 1.6 μg/kg) samples was 3.74 ± 0.72 μg/kg. The mean AFs in black and green tea were 2.65 ± 0.55 and 2.54 ± 0.40 μg/kg, respectively, while for OTA, the mean levels were 3.67 ± 0.96 and 3.46 ± 1.09 μg/kg in black and green tea samples, respectively. Four brands (10.8%) contained total aflatoxin levels above the EU limit (4 μg/kg). As for OTA, all samples had OTA levels below the Chinese limit (5 μg/kg). No significant association (p > 0.05) was found between OTA and tea type, level of packaging, country of origin, country of packing, and country of distribution. However, AF contamination was significantly (p < 0.05) higher in unpacked tea, and in brands where the country of origin, packing, and distributor was in Asia. The results showed that the tea brands in Lebanon are relatively safe in terms of AFs and OTA.

Evolution of COVID-19 infection characteristics in a Lebanese cohort of inpatients during different pandemic periods

This study aims to describe COVID-19 patients characteristics, laboratory and imaging results, and the different outcomes of patients admitted to the Lebanese American University Medical Center-Rizk Hospital over a period of 9 months. In this observational retrospective study, data were obtained from electronic medical records of 491 male and female patients from the ages of 17 to 97. Analysis of the patients was performed in 3 periods: August 2020 to October 20 November 202020 to January 2021 and February 2021 to April 2021 corresponding with 3 waves of newly diagnosed cases during this period. The sample showed a male predominance with an average age of 63. The average hospitalization length was 10.1 days. The majority of patients were discharged to quarantine. The distribution of hospitalized cases was significantly correlated to the monthly distribution of newly COVID-19 cases in Lebanon. There was no significant difference in patient's characteristics between the 3 periods of the study (gender, age, body mass index, smoking, and medical conditions). Clinical presentations of the patients varied between the 3 periods. Similarly, the course and outcome of infection varied. Patients received less oxygen during period 1, while more patients were cured during period 3. This study presents the first Lebanese cohort of COVID-19 patients with their medical background, clinical presentation, laboratory results, radiological findings and course of infection with its outcome. It also shows how the relations between the medical manifestation of the COVID-19 pandemic and the socio-political measures of infection control are deeply intertwined.

Effect of combination of prophylactic or therapeutic anticoagulation with aspirin on the outcomes of hospitalized COVID-19 patients: An observational retrospective study

Regimens for managing thromboembolic complications of COVID-19 are still not very well established. The present study compares the clinical characteristics and outcomes of patients hospitalized with COVID-19 receiving different anticoagulation regimens with and without aspirin. This is a retrospective observational study of 491 patients hospitalized for COVID-19 from August 2020 to April 2021. Data regarding clinical characteristics, laboratory findings, and outcomes of patients receiving different anticoagulation with and without aspirin regimens was collected, according to which 5 patient groups were defined: received no anticoagulation (NAA), prophylactic anticoagulation with (PA) or without aspirin (PAA) and therapeutic anticoagulation with (TA) or without aspirin (TAA). The average age was highest in the TAA group. Desaturation was highest in the TA and TAA groups. Diabetes, hypertension, dyslipidemia and coronary artery disease were the most prevalent in aspirin groups (PAA and TAA) as was heart failure in the TA and TAA groups and cancer in the TA and PAA groups. Elevated troponin was observed in the PAA and TAA groups. TA and TAA patients received oxygen therapy, needed ICU admission overall, and required invasive ventilation and vasopressors the most. Prophylactic anticoagulation groups (PA and PAA) had the highest patient survival rates. Patients with severe COVID-19 infections were more likely to receive higher, therapeutic, anticoagulation doses. Aspirin was given to patients with preexisting comorbidities, but it had no statistically significant impact on the outcomes of the different groups. Groups receiving prophylactic anticoagulation had the best survival outcomes.

Impact of social media education on antimicrobial stewardship awareness among pharmacy, medical and nursing students and residents

BACKGROUND

Antimicrobial resistance has always been an important issue as antimicrobial therapies are becoming less effective due to incorrect use and overuse. Our objective was to evaluate the impact of social media education on spreading antimicrobial stewardship awareness among healthcare students and residents.

METHODS

A prospective interventional study was conducted over 5 months, from November 2021 until March 2022. Weekly educational posts on infectious diseases were posted along with pre- and post- quizzes on a designated Facebook page. The primary endpoint of change in knowledge score was assessed using the independent t-test. Expected average pre-training is 2.5 over 5, and the expected average post-training is a minimum of 3.5 over 5 (common standard deviation of 1) for a minimum of 20% improvement that produces an effect size d = 1. Expecting a larger number of respondents on the pre-test than post-test, the ratio N1/N2 was set to 1.5. With the desired power set to 80% and alpha at 5%, sample size was determined as a minimum of 22 (N1) and 14 (N2). All analyses were carried at the 0.05 significance level.

RESULTS

In the entry questionnaire, 85.6% (107/125) of participants believed that antibiotics are overused, 26.4% (33/125) confirmed that they overuse antibiotics, and 88.8% (111/125) confirmed the importance of having an antimicrobial stewardship program. 76.8% (96/125) of the participants regularly use social media for educational purposes and only 2.4% sometimes refer to social media as an educational tool. Improvement in knowledge was noted in all pre and post - quizzes except for two quizzes (prostatitis and acute cystitis - 18.4% and 13.2% improvement respectively). In total, there was a significant 36.2% improvement between all pre and post quizzes [min 13.2% and max 52.8% across all quizzes].

CONCLUSION

This intervention demonstrated the importance of social media as a valuable tool to enhance antimicrobial stewardship knowledge among pharmacy, medical and nursing students and residents. Future studies are needed to examine the impact of social media education on behaviors in practice.

Burnout and coping strategies among health system pharmacists in Lebanon: a cross-sectional study

BACKGROUND

Burnout in health system pharmacists has been studied in several countries. To date, no data exists on burnout among healthsystem pharmacists in Lebanon. This study aimed to determine the prevalance of burnout, identify factors and describe coping strategies related to burnout among healthsystem pharmacists in Lebanon.

METHODS

A cross-sectional study utilizing the Maslach Burnout Inventory- Human Services Survey for Medical Personnel (MBI-HSS (MP))was conducted in Lebanon. A convenience sample of hospital pharmacists in Mount Lebanon and Beirut area filled a paper-based survey in person or via a phone interview. Burnout was defined as having an emotional exhaustion score ≥ 27 and/or depersonalization score ≥ 10. To identify factors associated with burnout, the survey also contained questions on socio-demographic characteristics, professional status, hospital characteristics, professional stressors and professional satisfaction. Participants were also asked about their coping strategies. To adjust for potential confounding, a multivariable logistic regression was used to estimate the adjusted odds ratios of factors and coping strategies associated with burnout. The authors also evaluated burnout according to the broader definition, emotional exhaustion score ≥ 27 or depersonalization score ≥ 10 or low personal accomplishment ≤ 33.

RESULTS

Of the 153 health system pharmacists who were contacted, 115 filled the survey (response rate of 75.1%). The overall burnout prevalence reported was n = 50 (43.5%) and was largely driven by high emotional exhaustion n = 41(36.9%). Following multivariate logistic regression, seven factors were associated with increased burnout: older age, B.S. in Pharmacy degree, involvement in student training, no involvement in procurement, divided attention at work, overall dissatisfaction with career, dissatisfaction to neutrality with balance between professional and personal life. Low personal accomplishment was noted in n = 55 (49.5%). The main coping strategies identified were holidays, leisure, hobbies, sports activities, and relaxation. There was no association between the coping strategies used and burnout. The prevalence of burnout according to the broader definition was n = 77 (67%). The factors associated with the broader definition of burnout were older age, overall dissatisfaction with career and dissatisfaction with work life balance.

CONCLUSION

Approximately n = 50(43.5%)of health system pharmacists in Lebanon may be at risk for burnout. If using broader definitions incorporating all three subscales of the (MBI-HSS (MP)), the prevalence of burnout was n = 77(67%). This study highlights the need to advocate for pratice reforms to improve the low personal acoomplishment and recommends strategies to mitigate burnout. Further research to assess the current prevalence of burnout and evaluate effective interventions in alleviating burnout amongst health system pharmacists is needed.

Reproductive health of Syrian refugee women in Lebanon: a descriptive analysis of the Sijilli electronic health records database

BACKGROUND

The Syrian conflict has been responsible for the highest exodus of refugees, with Lebanon hosting the greatest number of refugees per capita, which placed a significant strain on an already overburdened healthcare system. Women are the most vulnerable group in times of conflict and displacement, with sexual and reproductive health and rights often neglected. This study focuses on the obstetric characteristics and pregnancy outcomes of Syrian Refugee (SR) women in Lebanon, in Comparison to their pre-displacement data.

METHODS

This study is a secondary analysis of de-identified data from the Sijilli database. The data reported and analyzed were the refugees' socio-demographics, obstetric history, pregnancy outcomes, experienced maternal and neonatal complications, breastfeeding history and duration, and contraception use and types. Data were reported in both frequencies and means/medians. Chi-square test, t-test, and ANOVA tests were used to compare pregnancies in Syria to those that happened in Lebanon.

RESULTS

A total of 1065 female records were included in this study, with 634 ever-pregnant women and the total number of pregnancies being 3272. SR women were shown to get pregnant in Lebanon at a younger age compared to cases in Syria. The number of gravidities is equal in women who got pregnant in Syria and those who moved later to Lebanon. The mean spacing between pregnancies has decreased comparing SR women who got pregnant in Syria only versus those who got pregnant in Lebanon only. Among the mixed group, the mean spacing between pregnancies as well as the prevalence of spontaneous abortions significantly increased after displacing to Lebanon. C-section rate was higher among SR women after moving to Lebanon. Also, maternal complications and not breastfeeding have increased after moving to Lebanon. A prior pregnancy was significantly associated with higher contraception use rate. The most common methods of contraception were oral contraceptive pills and intra-uterine devices.

CONCLUSION

The C-section deliveries, spontaneous abortions and maternal complications have all increased among SR women after being displaced to Lebanon. While the age at first pregnancy, mean spacing between their pregnancies and breastfeeding rates have decreased after moving to Lebanon. SR women are less likely to use contraceptives after their displacement. It is necessary to address access to reproductive healthcare and antenatal care delivery among displaced refugee women living in informal tented settlements.

Predictors of surgical site infection following reconstructive flap surgery: A multi-institutional analysis of 37,177 patients

Purpose

Rates of surgical site infection (SSI) following reconstructive flap surgeries (RFS) vary according to flap recipient site, potentially leading to flap failure. This is the largest study to determine predictors of SSI following RFS across recipient sites.

Methods

The National Surgical Quality Improvement Program database was queried for patients undergoing any flap procedure from years 2005 to 2020. RFS involving grafts, skin flaps, or flaps with unknown recipient site were excluded. Patients were stratified according to recipient site: breast, trunk, head and neck (H&N), upper and lower extremities (UE&LE). The primary outcome was the incidence of SSI within 30 days following surgery. Descriptive statistics were calculated. Bivariate analysis and multivariate logistic regression were performed to determine predictors of SSI following RFS.

Results

37,177 patients underwent RFS, of whom 7.5% (n = 2,776) developed SSI. A significantly greater proportion of patients who underwent LE (n = 318, 10.7%) and trunk (n = 1,091, 10.4%) reconstruction developed SSI compared to those who underwent breast (n = 1,201, 6.3%), UE (n = 32, 4.4%), and H&N (n = 100, 4.2%) reconstruction (p < .001). Longer operating times were significant predictors of SSI following RFS across all sites. The strongest predictors of SSI were presence of open wound following trunk and H&N reconstruction [adjusted odds ratio (aOR) 95% confidence interval (CI) 1.82 (1.57-2.11) and 1.75 (1.57-1.95)], disseminated cancer following LE reconstruction [aOR (CI) 3.58 (2.324-5.53)], and history of cardiovascular accident or stroke following breast reconstruction [aOR (CI) 16.97 (2.72-105.82)].

Conclusion

Longer operating time was a significant predictor of SSI regardless of reconstruction site. Reducing operating times through proper surgical planning might help mitigate the risk of SSI following RFS. Our findings should be used to guide patient selection, counseling, and surgical planning prior to RFS.

Exposure Assessment of Aflatoxin B1 through Consumption of Rice in the United Arab Emirates

Rice is one of the most consumed staple foods worldwide and a major part of the diet for half of the global population. Being primarily cultivated in countries with warm and humid environments increases rice's susceptibility for mycotoxins contamination, especially the hepatotoxic and carcinogenic aflatoxin B1 (AFB1). Since no study was published before on the exposure to AFB1 from consuming rice in the UAE, our study aims to assess the levels of AFB1 in rice marketed in the country and determine the estimated daily exposure of the population for this carcinogenic metabolite and its associated liver cancer risk. All white, brown, and parboiled rice brands available in the retail markets in the UAE were procured twice. Using an enzyme-linked immunosorbent assay (ELISA) method, AFB1 was detected in 48 out of 128 rice samples (38%). The average contamination ± standard deviation of AFB1 among positive samples (above the detection limit) was found to be 1.66 ± 0.89 μg/kg, ranging from 1 μg/kg (detection limit) to 4.69 μg/kg. The contamination level in all the samples was below the limit set by the Gulf Cooperation Council Standardization Organization (≤5 μg/kg), while 10 (20.8%) of the positive samples had a contamination level above the maximum limit set by the European Union (≥2 μg/kg). The moisture content in all the assessed samples was ≤14%. Furthermore, there was a significant difference in AFB1 between samples in both collections (p-value = 0.043). However, the rice type, grain size, packing country, packing season, country of origin, collection season, and packing to purchasing time had no significant effect on AFB1. The calculated mean daily exposure level of the Emirati population to AFB1 from consuming rice was 4.83 ng/kg.

Intravenous high dose vitamin C and selected antiviral drugs in hospitalized COVID-19 patients: a descriptive cohort study

Introduction: There is lack of universal agreement on the management of COVID-19. Intravenous high dose vitamin C (HDVC), remdesivir (RDV), and favipiravir (FPV) have been suggested as part of the treatment regimens and only RDV is approved by the Food and Drug Administration (FDA) so far. There is no study in Lebanon that addresses the descriptive cohort of HDVC and antiviral therapy amongst COVID-19 inpatients. Our goal was to highlight such a cohort. Methodology: A retrospective electronic chart review of COVID-19 inpatients was done over a period of 10 months (August 2020 to April 2021). Comparative data analysis was performed between HDVC and non-HDVC (NHDVC) groups, and RDV and FPV groups. Results: Among HDVC patients, 70.1% (p = 0.035) and 67.2% (p = 0.008) had dyspnea and desaturation respectively. Patients on HDVC were less likely to remain in hospital for more than 20 days (p = 0.003). HDVC patients were more likely to be on oxygen therapy with 74.7% (p = 0.002). RDV patients were more likely to be on other COVID-19-related medications during hospitalization including the use of tofacitinib, baricitinib, tocilizumab, and anticoagulation as recommended in the guidelines. Statistical significance was noted for the status on discharge as 90.1% of the patients that received RDV were discharged after clinical improvement, compared to the 74.2% of the FPV patients. Conclusions: Further research is needed to establish local guidelines for the treatment of COVID-19. A significant role of HDVC and FPV might resurface if randomized control trials are conducted.

Vaccination process evaluation at COVID-19 vaccination centers in Lebanon: a national study

Background

Upon the authorization of COVID-19 vaccines worldwide, national and international standards were developed to help integrate mass COVID-19 immunization campaigns into the healthcare network. The primary objective is to evaluate the overall COVID-19 vaccination process through on-site visits to vaccination centers all over Lebanon to assess whether these are abiding by the national and international requirements for both Pfizer-BioNTech and AstraZeneca vaccines. The secondary objective is to explore whether the type of the facility, private versus governmental, and educational versus non-education, affects the vaccination process in these centers.

Methods

A convenient sample of 33 vaccination centers was selected from a list of all COVID-19 vaccination centers operating in Lebanon. Data were collected using a structured checklist developed following an extensive literature review of the national and international standards for Pfizer-BioNTech and AstraZeneca COVID-19 vaccines. A scoring system for the overall vaccination process was developed.

Results

Quality deficiencies were identified in several steps of the immunization process; however, the international standards were followed in most vaccination centers visited despite their limited resources. It was noticed that there were no significant differences between private and governmental, between educational and non-educational, and between Pfizer and AstraZeneca vaccination centers; the 33 vaccination centers visited have scored above 75 on the entire process immunization against COVID-19 with P-values above 0.05 in all steps evaluated.

Conclusion

An optimization of the immunization process should be performed to ensure that the practice is within international standards. This can be done by conducting periodic vaccination center visits, implementing clear guidelines, training staff involved in the vaccination process, and ensuring continuous support of the Lebanese Ministry of Public Health.

Microbiological safety of commercial canned and dry pet food products in Lebanon

Estimating the microbiological quality of pet food is essential in providing healthy and safe foods to pets. The aim of this study was to assess the microbiological safety of pet food marketed in Lebanon, namely cat and dog products. To the best of our knowledge, no studies have been conducted in Lebanon nor the Middle East region with reference to pet food quality. Lebanese market was screened and a total of 165 dry and canned pet food products were identified, collected and analyzed for their load of total aerobic microbial count, Enterobacteriaceae species, yeasts and molds, and for the presence of Salmonella and Listeria species. Dry pet food products had higher contamination level compared to canned ones. In terms of non-conformity to the European commission regulations, out of the 165 brands, 11 (7%) had a total aerobic microbial count above 10⁶ cfu/g, and 27 (16%) exceeded 3 × 10² cfu/g as a maximum limit of presumptive Enterobacteriaceae. Among the dry brands, 8 out of 66 (12%) had a contamination level of yeasts and molds above 10⁴ cfu/g. Presumptive Salmonella spp. was detected in 68 (41%) and presumptive Listeria spp. in 106 (64%) of brands. These alarming results necessitates setting and monitoring microbiological standards for pet food in Lebanon. This study contributes as well to the building of a database for knowledge development regarding the potential contamination of pet food by the abovementioned microorganisms.

Exposure to Ochratoxin A from Rice Consumption in Lebanon and United Arab Emirates: A Comparative Study

Our study aims to evaluate the ochratoxin A (OTA) in rice marketed in Lebanon and the United Arab Emirates (UAE), and to determine the exposure to OTA from rice consumption. All brands available in the market were collected twice (total number of collected samples: 105 and 127 in Lebanon and the UAE, respectively). Using ELISA, the OTA in 56 (53%) samples in Lebanon and 73 (58%) samples in the UAE were above the limit of quantification (0.8 μg/kg). The average concentrations of the positive samples ± standard deviations were 1.29 ± 0.32 and 1.40 ± 0.42 μg/kg in Lebanon and the UAE, respectively. Only one sample (1%) in Lebanon had a level at the borderline of the European Union (EU) limit, and two samples (1.6%) in the UAE had a level above the EU limit (5 μg/kg). The OTA in brown rice was higher than in white and parboiled rice for both countries, yet the difference was not significant. The packing season, packing country, and country of origin did not have any significant effects. The presence of a food safety certification resulted in lower OTA in the rice, but the difference was significant (p = 0.04) in the UAE only. Long grains had higher OTA than short grains, yet the difference was only significant in Lebanon (p = 0.046). The exposures were calculated as 1.27 ng/kg body weight/day in Lebanon and 1.42 ng/kg body weight/day in the UAE, and no health risk was observed for both the neoplastic and non-neoplastic effects.

The determinants of the quality of clinical management among diabetic and hypertensive patients in a context of fragility: A cross-sectional survey from Lebanon

Introduction

The management of NCDs is a growing challenge in low- and middle-income settings with the increasing prevalence and the associated demands that such conditions make on health systems. Fragile settings both exacerbate the risk of NCDs and undermine systems capacity. Lebanon is a setting where strategies to address rising NCDs burden have faced particularly acute contextual challenges.

Methods

We conducted a cross-sectional survey with patients accessing non-communicable disease across 11 primary care centers within the Greater Beirut and Beqaa areas. Response were received from 1,700 patients. We generated a Clinical Management Index Score as a measure of quality of care, and scores related to a range of socio-demographic characteristics and other context specific variables.

Results

Significantly higher clinical management index scores (better quality of care) were associated with patients living in the semi-urban/rural context of Beqaa (compared to Greater Beirut), having health insurance coverage, aged above 60, having high levels of educational attainment, and making partial or full payment for their treatment. Relatively lower index scores (poorer quality of care) were associated with Syrian nationality (compared to Lebanese) and with patients suffering from diabetes or hypertension (compared to comorbid patients).

Conclusion

The study identified a wide margin for improving quality of NCDs care in fragile contexts with particular gaps identified in referral to ophthalmology, accessing all prescribed medication and receiving counseling for smoking cessation. Additionally, findings indicate a number of predictors of comparatively poor quality of care that warrant attention, notably with regard to Syrian nationality/legal status, lack of health coverage, seeking free health provision and lower educational attachment. Although these are all relevant risk factors, the findings call on donor agencies, NGOs and provider institutions to design targeted programs and activities that especially ensure equitable delivery of services to diabetic and hypertensive patients with compounded vulnerability as a result of a number of these factors.

Aflatoxin B1 in Rice: Effects of Storage Duration, Grain Type and Size, Production Site, and Season

ABSTRACT

Our study evaluated aflatoxin B1 (AFB1) levels in packed rice marketed in Lebanon and determined the exposure to this toxin from rice consumption. A total of 105 packed white, parboiled, and brown rice bags were collected. Enzyme-linked immunosorbent assay was used to measure AFB1. A comprehensive food frequency questionnaire was completed by 500 participants to determine patterns of rice consumption and, subsequently, the exposure levels to AFB1 from rice consumption in Lebanon. AFB1 was detected in all rice samples (100%). The average concentration ± standard deviation of AFB1 was 0.5 ± 0.3 μg/kg. Contamination ranged between 0.06 and 2.08 μg/kg. Moisture content in all rice samples was below the recommended percentage (14%). Only 1% of the samples had an AFB1 level above the European Union limit (2 μg/kg). Brown rice had a significantly higher AFB1 level than white and parboiled rice (P = 0.02), while a significant difference was found between both collections for the same brands (P = 0.016). Packing season, packing country, country of origin, presence of a food safety management certification, grain size, and time between packing and purchasing had no significant effect. Exposure to AFB1 from rice consumption in Lebanon was calculated as 0.1 to 2 ng/kg of body weight per day.

HIGHLIGHTS

Outpatient use patterns and experiences among diabetic and hypertensive patients in fragile settings: a cross-sectional study from Lebanon

OBJECTIVES

Assess and describe the health service use and delivery patterns for non-communicable disease (NCD) services in two contrasting fragility contexts and by other principal equity-related characteristics including gender, nationality and health coverage.

SETTING

Primary healthcare centres located in the urbanised area of Greater Beirut and the rural area of the Beqaa Valley.

DESIGN

This is a cross-sectional study using a structured survey tool between January and September 2020.

PARTICIPANTS

1700 Lebanese and Syrian refugee patients seeking primary care for hypertension and diabetes.

PRIMARY AND SECONDARY OUTCOMES

The main outcome is the comprehensiveness of service delivery comparing differences in use and service delivery patterns by fragility setting, gender, nationality and health coverage.

RESULTS

Compliance with routine NCD care management (eg, counselling, immunisations, diagnostic testing and referral rates) was significantly better in Beirut compared with Beqaa. Women were significantly less likely to be offered lifestyle counselling advice and referral to cardiologists (58.4% vs 68.3% in Beqaa and 58.1% vs 62% in Beirut) and ophthalmologists, compared with men. Across both settings, there was a significant trend for Lebanese patients to receive more services and more advice related to nutrition and diabetes management (89.8% vs 85.2% and 62.4% vs 55.5%, respectively). Similarly, referral rates were higher among Lebanese refugees compared with Syrian refugees. Immunisation and diagnostic testing were significantly higher in Beirut among those who have health coverage compared with Beqaa.

CONCLUSIONS

The study discovered significant differences in outpatient service use by setting, nationality and gender to differentials. A rigorous and comprehensive appraisal of NCD programmes and services is imperative for providing policy makers with evidence-based recommendations to guide the design, implementation and evaluation of targeted programmes and services necessary to ensure equity in health services delivery to diabetic and hypertensive patients. Such programmes are an ethical imperative considering the protracted crises and compounded fragility.

Prevalence of non-communicable diseases and associated medication use among Syrian refugees in Lebanon: an analysis of country-wide data from the Sijilli electronic health records database

Background

Globally, the number of forcibly displaced individuals has reached 70.8 million. Lebanon, a middle income country, hosts the highest number of refugees per capita worldwide. The majority of refugees are Syrians who have fled the Syrian war that started in 2011. The migration journey exposes refugees to increased susceptibility to a wide range of medical issues including non-communicable diseases (NCDs). This study aims to determine the prevalence of NCDs among adult Syrian refugees in Lebanon, with a focus on hypertension, diabetes, cardiovascular diseases (CVD) and cancer. The study also aims to explore factors potentially related to the prevalence figures and understand the medication use associated with these morbidities.

Methods

This study is a secondary analysis of de-identified data from the “Sijilli Electronic Health Records for Refugees” Database comprising data on 10,082 Syrian refugees from across informal tented settlements located all over Lebanon. A total of 3255 records of Syrian refugees aged above 18 years old and reporting having at least one condition of the following were included in the analysis: hypertension, diabetes, cardiovascular diseases or cancer. Pearson’s Chi-square, independent t-test, and multivariate logistic regressions were used for data analysis.

Results

Hypertension was the most prevalent (10.0%) NCD among refugees, and a higher age was associated with higher NCDs prevalence. A strong linkage has been reported between smoking status and alcohol intake, and increased risk for NCDs. Study findings also revealed that the hypertension, diabetes and CVDs were mainly observed among refugees originating from Idlib, Aleppo and Homs. An association between medication use and location of diagnosis was noted, with females who were diagnosed before moving to Lebanon being more likely to take corresponding medications compared to those diagnosed in Lebanon, with no difference reported among males.

Conclusions

Our findings suggest that efforts should be directed towards the employment of innovative low-cost approaches for NCD detection and control among refugees, with a focus on the importance of use of adequate medication. Such efforts remain imperative to control the increasing burden of NCDs amongst refugee populations and improve equitable access to NCD services.

Curricular integration of the pharmacists' patient care process

INTRODUCTION

The Accreditation Council for Pharmacy Education Standard 10 specifies the need to prepare students to provide patient-centered collaborative care. The aim of this study is to assess the impact of a newly introduced Pharmacists' Patient Care Process (PPCP) based laboratory course on students' perception of their preparedness to apply PPCP steps in introductory pharmacy practice experiences (IPPEs).

METHODS

The PPCP was introduced into the Pharmaceutical Care and Dispensing Laboratory course during the second professional year. Students' self-perception of preparedness to apply the PPCP was assessed via a survey composed of questions related to PPCP skillsets. The pre-PPCP laboratory cohort (control group) took the survey after the completion of their IPPEs. The PPCP laboratory cohort (intervention group) took the same survey prior to taking the course, at the end of the course, and following the completion of their IPPEs. Pearson's and McNemar chi-square tests were used for statistical analyses.

RESULTS

The findings indicate that the PPCP-based laboratory significantly improved students' perception of their preparedness to apply a standardized pharmacist care process to verify prescriptions, to collect relevant patient information, and to develop an individual patient-centered care plan. This significant impact of the PPCP-based laboratory course on students' perception was maintained through the following year when assessed after IPPEs.

CONCLUSIONS

Introduction of the PPCP model within a dispensing laboratory course, prior to students' IPPEs, develops students' perception of preparedness. Incorporating the PPCP via active learning and simulation narrows the gap between the didactic and experiential curriculum.

Health-Related Quality of Life in Patients with Health Conditions in Lebanese Community Setting

Background: The measurement of health-related quality of life (HRQoL) provides utility scores that could be used for health economics assessment. The aim of this study was to measure HRQoL in Lebanese patients with certain medical conditions, and to determine demographic and medical factors affecting such health utility scores. Method: This was a prospective cross-sectional pilot study conducted to gather information on the socioeconomic status, health condition and quality of life of participants with common diseases during their community pharmacy visit. The EuroQol-5-Dimension instrument was used to measure utility scores and SPSS v26 was used to perform the statistical analysis. Results: Participants (n = 102) gave an average of 6.8 and 7.4 out of 10 for their current health and for their satisfaction with their treatment, respectively. The mean utility score was 0.762 (SD 0.202). The number of prescribed medications per respondent indicated a significant impact on HRQoL (p = 0.002). On average, the utility scores were low for participants who were 75 years or older (0.15, p < 0.001), and those who were hospitalized in the past 12 months (0.111, p < 0.001). For every unit increase in treatment satisfaction, the quality-of-life score increased by 0.036 unit (p = 0.001). Conclusion: This pilot study measured health utility scores and factors influencing HRQoL in the Lebanese population. Further studies are needed to confirm our findings and to develop and validate tools helping to measure health related quality of life in the population in Lebanon.

Food shopping and food hygiene related knowledge and practices during the COVID-19 pandemic: The case of a developing country

The aim of this study was to assess the level of food hygiene and food shopping knowledge and practices among residents of Lebanon during the COVID-19 pandemic, and to identify their socio-demographic determinants. A cross-sectional study was conducted through an online questionnaire composed of 13 questions about demographics, and 25 questions related to knowledge and practices in terms of hand maintenance, mask placing, and food shopping. A total of 1337 participants filled the survey. On average, participants scored 73±15 and 67±17% on food hygiene and knowledge and practices, respectively. In terms of best practices by section, they scored 77±22, 51±42, and 65±23% on hand maintenance, mask placing and shopping, respectively. Hand maintenance best practices score was significantly (p<0.05) affected by gender; mask placing best practices score was significantly affected by age and major of study; shopping best practices score was significantly affected by gender; overall best practices score was significantly affected by gender and major of study; food hygiene knowledge score was significantly affected by gender, age, marital status, educational level, and major of study. Food hygiene practices and knowledge scores were significantly (p<0.001) related with a weak correlation coefficient (R=0.114). No study has determined the food hygiene and shopping knowledge and practices during the COVID-19 pandemic in a developing country before.

Prevalence of depression symptoms and associated sociodemographic and clinical correlates among Syrian refugees in Lebanon

BACKGROUND

Since the outbreak of the Syrian war in 2011, close to 6 million Syrian refugees have escaped to Syria's neighbouring countries, including Lebanon. Evidence suggests rising levels of mental health disorders among Syrian refugee populations. Yet, to the best of our knowledge, large-scale studies addressing the mental health of adult Syrian refugees in Lebanon are lacking. We examined the prevalence of depression symptoms, which represent a common and debilitating mental health disorder among Syrian refugee populations in Lebanon, along with their sociodemographic and clinical correlates.

METHODS

A cross-sectional survey design was conducted as part of a collaborative project-"Sijilli"- led by the Global Health Institute at the American University of Beirut (Beirut, Lebanon) across 4 informal tented settlements for refugees (Beirut, Bekaa, North, South) in Lebanon among adult Syrian refugees (≥18), over a period extending from 2018 to 2020. The survey inquired about participants' sociodemographic and clinical characteristics, and screened participants for symptoms of depression through sequential methodology using the Patient Health Questionnaire (PHQ-2 and PHQ-9).

RESULTS

A total of 3255 adult Syrian refugees were enrolled in the study. Of those refugees, 46.73% (n = 1521) screened positive on the PHQ-2 and were therefore eligible to complete the PHQ-9. In the entire sample (n = 3255), the prevalence of moderate to severe depression symptoms (PHQ-2 ≥ 2 and then PHQ-9 ≥ 10) was 22% (n = 706). Further analyses indicate that being ≥45 years of age (OR 1.61, 95% CI 1.13-2.30), a woman (OR 1.34, 95% CI 1.06-1.70), widowed (OR 2.88, 95% CI 1.31-6.32), reporting a neurological (OR 1.73, 95% CI 1.15-2.60) or a mental health condition (OR 3.98, 95% CI 1.76-8.97) are major risk factors for depression.

CONCLUSION

Our study suggests that an estimated one in four Syrian refugees in Lebanon shows moderate to severe depression symptoms, and our findings have important public health and clinical implications on refugee health. There is a need to enhance screening efforts, to improve access and referral to mental health services, and to improve post-migration factors among Syrian refugees in Lebanon.

Views of community pharmacists in Lebanon on the unified prescription: a mixed method study

Background

The unified prescription was introduced in Lebanon in 2011; an aim was to save on medication expenditure.

Aims

The aim of this study was to evaluate the views of community pharmacists on the effect and usefulness of the unified prescription.

Methods

A cross-sectional telephone survey of community pharmacists from all governorates of Lebanon was conducted. A questionnaire was used to collect demographic data, pharmacists' views on the effect of the unified prescription on their work, the percentage of prescriptions in which the prescriber had indicated that the medicine should not be substituted with a generic equivalent and the percentage needing clarification from the prescriber. Face-to-face interviews were held with 12 pharmacists to explore their views further.

Results

Of 251 pharmacists interviewed, 56.8% did not think the unified prescription was useful, 34.8% thought it complicated their work and 24.0% that it reduced their autonomy. The in-depth interviews showed that autonomy was perceived to be restricted because of the difficulty in convincing patients to accept a substitute generic medicine, which the unified prescription allowed. The unified prescription complicated pharmacists' work because of increased paperwork and the need for more storage. Pharmacists felt that the large number of prescriptions in which the prescriber had indicated that the medicine should not be substituted undermined the purpose of the unified prescription.

Conclusion

The implementation of the unified prescription was not considered a success by community pharmacists in Lebanon. Efforts are needed to improve communication with prescribers and educate the public about pharmacists' role and generic medicines.

Determination of Aluminum, Chromium, and Barium Concentrations in Infant Formula Marketed in Lebanon

ABSTRACT

Infant formula is a major nutritional component for many infants and toddlers. However, the presence of contaminants, such as toxic metals, may pose increased health risks to infants. An investigation of the total concentrations of the metals aluminum (Al), barium (Ba), and chromium (Cr) in infant formulae marketed in Lebanon was performed. Powdered dairy and nondairy infant formula samples were collected from all commercially available brands (n = 39) in the Lebanese market on two production dates (78 samples in total) and analyzed for these three metals with inductively coupled plasma mass spectrometry. All brands contained detectable concentrations of Al and Ba, Cr was detected in 95% of brands. Mean (±standard deviation) concentrations of the metals were estimated as 1.54 ± 1.43 (Al), 0.256 ± 0.593 (Ba), and 0.168 ± 0.143 (Cr) (μg/g). The concentration ranges in the powdered formula were 0.080 to 7.93 (Al), 0.038 to 5.35 (Ba), and 0.041 to 0.348 (Cr) μg/g. A significant difference in the mean concentrations of Al, Ba, and Cr for the two production dates of a single brand was observed in 92, 59, and 83% of samples, respectively. The mean concentration of Al in the soy-based formula was significantly higher than that of aluminum in milk-based and corn-based formulas (P = 0.018). Cr concentrations in the continuation special formulations were significantly higher than those in the beginner formulations (P = 0.008). Our study provides the first publicly available information on metal contamination in infant formulas in Lebanon and reveals the need for frequent monitoring and surveillance of these products intended for infant consumption.

HIGHLIGHTS

GC-MS analysis of polycyclic aromatic hydrocarbons in bottled olive oil marketed in Lebanon

Lebanon has witnessed elevated levels of pollution over the last few years due to increased waste incineration, emissions from vehicles and electricity generators, and mass demonstrations involving the burning of tires. The resultant generation of polycyclic aromatic hydrocarbons (PAHs) from the incomplete combustion of organic materials present in these sources may contaminate various foods including olive oil. Lebanon has a sizeable olive oil industry that is a main pillar of its agricultural sector. In this study, we investigated the occurrence of 16 semi-volatile lipophilic organic pollutants in 25 bottled olive oil brands, marketed in Lebanon, using a solid phase extraction (SPE) method followed by gas chromatography mass spectrometry (GC-MS). PAHs were detected in 60% of brands (41% of samples) where 12% of brands contained traces of probably carcinogenic (Class 2A) compounds and 56% of brands contained traces of possibly carcinogenic (Class 2B) compounds. One brand revealed levels of benzo[a]pyrene of 9.45 μg/kg and 11.9 μg/kg in batches collected over two production dates which are higher than the limit set by the European Commission for benzo[a]pyrene in food (2 μg/kg). The same batches contained a total of 19.3 μg/kg and 26.7 μg/kg of the four PAHs: benzo[a]pyrene, benz[a]anthracene, benzo[b]fluoranthene, and chrysene which also exceeded the limit set by the EC for the combination of these four PAHs in olive oil (10 μg/kg). This study is the first-of-its-kind in Lebanon and emphasizes the need to perform adequate cleanup steps in the manufacturing process in order to reduce the content of carcinogenic PAHs in olive oil.

mHealth use for non-communicable diseases care in primary health: patients' perspective from rural settings and refugee camps

Background

Non-communicable diseases (NCDs) account for 85% of deaths in Lebanon and contribute to remarkable morbidity and mortality among refugees and underserved populations. This study assesses the perspectives of individuals with hypertension and/or diabetes in rural areas and Palestinian refugee camps towards a population based mHealth intervention called 'eSahha'.

Methods

The study employs a mixed-methods design to evaluate the effectiveness of SMSs on self-reported perceptions of lifestyle modifications. Quantitative data was collected through phone surveys, and qualitative data through focus group discussions. Descriptive statistics and bivariate analysis were performed.

Results

About 93.9% (n = 1000) of respondents perceived the SMSs as useful and easy to read and understand. About 76.9% reported compliance with SMSs through daily behavioral modifications. Women (P = 0.007), people aged ≥76 years (P < 0.001), unemployed individuals (P < 0.001), individuals who only read and write (P < 0.001) or those who are illiterate (P < 0.001) were significantly more likely to receive and not read the SMSs. Behavior change across settings was statistically significant (P < 0.001).

Conclusion

While SMS-based interventions targeting individuals with hypertension and/or diabetes were generally satisfactory among those living in rural areas and Palestinian refugee camps in Lebanon, a more tailored approach for older, illiterate and unemployed individuals is needed.

Keywords

e-health, refugees.

Immediate and long-term results of percutaneous mitral commissurotomy: up to 15 years

PURPOSE

To evaluate immediate and long-term clinical results of percutaneous mitral commissurotomy (PMC) in patients with severe mitral stenosis.

METHODS

In a retrospective study, data were included from 317 patients over 18 years of age (mean age 45) who had been treated for mitral stenosis between January 1993 and March 2015 with PMC using the Inoue balloon technique. Immediate results: Valvular function improved as evidenced by an increase in mitral valve area from 1.01 ± 0.24 cm² to 2 ± 0.31 cm² (P < 0.001) and a decrease in mean mitral gradient from 13.64 ± 6.03 mm Hg to 5.40 ± 2.49 mm Hg. Long-term follow-up: At 5-15 years (mean 10.2 years, Inter-quartile range 8.25), 105 (33.1%) of the 317 patients were available for follow-up, 95 living patients and 10 deceased. Of the deceased, average time from PMC to death was 8 years. Results were strongly significant showing that age at the time of PMC and surface area before the procedure were the best predictors of survival at 15 years follow-up, showing significance values of P = 0.022 and P = 0.001, respectively.

CONCLUSIONS

PMC using the Inoue balloon technique improves morbidity and long-term mortality rates in patients with severe mitral stenosis. Lower Wilkins score and NYHA class at baseline were not found to be significant predictors of mortality in older patients (age > 45). Overall, 65 (61.9%) had survived at 5-15 years follow-up without further cardiac intervention.

Evaluation of prophylactic dosages of Enoxaparin in non-surgical elderly patients with renal impairment

Background

Thromboprophylaxis dosing strategies using enoxaparin in elderly patients with renal disease are limited, while dose adjustments or monitoring of anti-Xa levels are recommended. We sought to evaluate the efficacy and safety of enoxaparin 20 mg versus 30 mg subcutaneously daily by comparing anti-Xa levels, thrombosis and bleeding.

Methods

We conducted a prospective, single-blinded, single-center randomized clinical trial including non-surgical patients, 70 years of age or older, with renal disease requiring thromboprophylaxis. Patients were randomized to receive either 20 mg or 30 mg of enoxaparin. The primary endpoint was peak anti-Xa levels on day 3. Secondary endpoints included trough anti-Xa levels on day 3, achievement of within range prophylactic target peak anti-Xa levels and the occurrence of hemorrhage, thrombosis, thrombocytopenia or hyperkalemia during hospitalization.

Results

Thirty-two patients were recruited and sixteen patients were randomized to each arm. Mean peak anti-Xa level was significantly higher in 30 mg arm (n = 13) compared to the 20 mg arm (n = 11) 0.26 ± 0.11, 95%CI (0.18–0.34), versus 0.14 ± 0.09, 95CI (0.08–0.19) UI/ml, respectively; p = 0.004. Mean trough anti-Xa level was higher in 30 mg arm (n = 10) compared to the 20 mg arm (n = 16), 0.06 ± 0.03, 95CI (0.04–0.08) versus 0.03 ± 0.03, 95CI (0.01–0.05) UI/ml, respectively; p = 0.044. Bleeding events reported in the 30 mg arm were one retroperitoneal bleed requiring multiple transfusions, and in the 20 mg arm one hematuria. No thrombotic events were reported.

Conclusion

Peak anti-Xa levels provided by enoxaparin 20 mg were lower than the desired range for thromboprophylaxis in comparison to enoxaparin 30 mg.

Trial registration

The trial was retrospectively registered on ClinicalTrials.gov identifier: NCT03158792. Registered: May 18, 2017.

Use of over the counter products in older cardiovascular patients admitted to a tertiary care center in USA

BACKGROUND

In recent years there has been a substantial increase in the use of over-the-counter (OTC) products around the world. While they are assumed to be safe by consumers, they can potentially lead to adverse effects and drug interactions particularly in older adults.

METHODS

We assessed the patterns of OTC products used by older adults admitted to the cardiology service in a tertiary care medical center in the USA over a three month period. We conducted a retrospective chart review where older adults with cardiovascular diseases (CVD) who were taking at least one OTC product at home were included.

RESULTS

Out of 404 patients who were admitted to the cardiology service, 281 (69.6%) were taking OTC products. Patients were taking a total of 659 OTC products; mean of 2.35 ± 1.57 and the range varied from 1 to 9 products. The most commonly used products were vitamins (37.3%), followed by laxatives (17%), minerals (13.6%), stomach acid reducers (9%), and analgesics (3.6%). OTC users were found to be suffering from more comorbidities and received more prescription medications as compared to non-users. Gender and age did not have an impact on the use of OTC products while patients with atrial fibrillation, sleep apnea and gastro-esophageal reflux disease were more likely to use OTC products.

CONCLUSION

Use of OTC products is quite frequent in older adults with CVD in our study. Clinicians should ask about OTC product usage and counsel patients about the risks and benefits associated with their use.

Using Mobile Health to Enhance Outcomes of Noncommunicable Diseases Care in Rural Settings and Refugee Camps: Randomized Controlled Trial

BACKGROUND

Rural areas and refugee camps are characterized by poor access of patients to needed noncommunicable disease (NCD)-related health services, including diabetes and hypertension. Employing low-cost innovative eHealth interventions, such as mobile health (mHealth), may help improve NCDs prevention and control among disadvantaged populations.

OBJECTIVE

The aim of this study was to assess the effect of employing low-cost mHealth tools on the accessibility to health services and improvement of health indicators of individuals with NCDs in rural areas and refugee camps in Lebanon.

METHODS

This is a randomized controlled trial study in which centers were allocated randomly into control and intervention sites. The effect of an employed mHealth intervention is assessed through selected quality indicators examined in both control and intervention groups. Sixteen primary health care centers (eight controls, eight interventions) located in rural areas and Palestinian refugee camps across Lebanon were included in this study. Data on diabetic and hypertensive patients-1433 in the intervention group and 926 in the control group-was extracted from patient files in the pre and postintervention periods. The intervention entailed weekly short message service messages, including medical information, importance of compliance, and reminders of appointments or regular physician follow-up. Internationally established care indicators were utilized in this study. Descriptive analysis of baseline characteristics of participants, bivariate analysis, logistic and linear regression were conducted using SPSS (IBM Corp).

RESULTS

Bivariate analysis of quality indicators indicated that the intervention group had a significant increase in blood pressure control (P=.03), as well as a significant decrease in the mean systolic blood pressure (P=.02), mean glycated hemoglobin (HbA_1c; P<.01), and in the proportion of HbA_1c poor control (P=.02). Separate regression models controlling for age, gender, and setting showed a 28% increase in the odds of blood pressure control (P=.05) and a 38% decrease in the odds of HbA_1c poor control (P=.04) among the intervention group in the posttest period. Females were at lower odds of HbA_1c poor control (P=.01), and age was statistically associated with annual HbA_1c testing (P<.01). Regression models for mean systolic blood pressure, mean diastolic blood pressure, and mean HbA_1c showed that a mean decrease in HbA_1c of 0.87% (P<.01) pretest to posttest period was observed among the intervention group. Patients in rural areas belonging to the intervention group had a lower HbA_1c score as compared with those in refugee camps (P<.01).

CONCLUSIONS

This study underlines the importance of employing integrative approaches of diseases prevention and control in which existing NCD programs in underserved communities (ie, rural and refugee camps settings) are coupled with innovative, low-cost approaches such as mHealth to provide an effective and amplified effect of traditional NCD-targeted care that can be reflected by improved NCD-related health indicators among the population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03580330; https://clinicaltrials.gov/ct2/show/NCT03580330 (Archived by WebCite at http://www.webcitation.org/70mhVEUwQ).

Patterns of pain medication use in older individuals with cardiovascular disease

BACKGROUND

Pain is common in older adults and clinicians are often faced by many challenges when selecting appropriate treatment due to age-related changes in pharmacokinetics, pharmacodynamics, increased comorbidities, and polypharmacy.

METHODS

This study assessed the patterns of pain medications used at home among older adults admitted to the cardiology service in a tertiary care teaching center in the US from March to May 2016. A retrospective chart review was conducted where adults, 65 years of age or older, with cardiovascular diseases admitted to the cardiology service and taking at least one pain medication at home were studied.

RESULTS

Out of 404 patients who were admitted to the cardiology service, 228 (56.4%) were on at least one pain medication. Among the admitted patients, 64.2% of the females received at least one pain medication, as compared to 49% of the males (p = 0.002). Participants had a mean age of 76.34 ± 7.43 years, and received a mean of 1.81 ± 0.83 pain medications. Neuropathic pain was the most common indication (33.4%), followed by arthritis (17.5%), and cancer (15.8%). The most commonly used pain medications were gabapentin/pregabalin 79 (34.6%), acetaminophen plus an opiate 78 (34.2%), opiates 56 (24.6%), tramadol 36 (15.8%), followed by non-selective NSAIDs 21 (9.2%). Twelve (5.3%) patients received duplication of pain medications, while 14 (5.7%) received an inappropriate combination of pain medications. Twenty-three patients (10.1%) received muscle relaxants in conjunction with pain medications, 20 of which are considered poorly tolerated by older adults.

CONCLUSION

This stufy described the patterns of use of pain medications among older adults with cardiovascular disease. Careful selection of appropriate pain medications based on different clinical parameters is very essential to avoid prescribing inappropriate therapy that can lead to patient harm.

Immediate vs conventional loading of variable-thread tapered implants supporting three- to four-unit fixed partial dentures in the posterior maxilla: 1-year interim results of a split-mouth randomised controlled trial

PURPOSE

To compare the outcome of immediately loaded and one-stage conventionally loaded variable-thread tapered implants in the posterior maxilla.

MATERIALS AND METHODS

This study was designed as a split-mouth randomised controlled trial. Twenty-six patients missing teeth bilaterally in the posterior maxilla received three to four implants in each of the posterior sextants. Bone quality was recorded based on Misch criteria (D1-D4) and insertion torque values were measured using a manual wrench. The implants on one side were immediately loaded with a temporary resin fixed partial denture on definitive multi-unit abutments. The implants in the contralateral side received definitive multi-unit abutments according to the one-stage unloaded protocol. Three to 3.5 months following implant placement, the implants were restored with metal-ceramic fixed prostheses. Outcome measures were implant and prosthesis failure rates, complications, and peri-implant bone level changes at 1 year following delivery of the definitive prostheses.

RESULTS

Two patients dropped out prior to the delivery of definitive prostheses. Four implants supporting a four-unit immediately loaded prosthesis failed in one patient, 3 months following delivery of the definitive prostheses. None of the conventionally loaded implants or prostheses failed. There were no significant differences in the proportions of implant and prosthesis failures (difference = 4.2%; 95% CI -4.2 to 12.6%; P = 0.999). In the immediately loaded group, four early prosthetic complications occurred during the provisionalization phase (three small resin chippings and one prosthetic screw loosening). No other complications were reported. The difference in the rate of complications between the two interventions was not statistically significant (difference = 16.7%; 95% CI -1.2% to 35.6%; P = 0.125). The 1-year peri-implant marginal bone level changes were evaluated in 23 patients (77 immediately loaded and 76 conventionally loaded implants). On average, patients lost 0.42 mm at the immediately loaded and 0.46 mm at the conventionally loaded implants, the difference being statistically not significant (difference = 0.044 mm; 95% CI -0.27 to 0.18 mm; P = 0.701).

CONCLUSIONS

Immediate loading of 3- to 4-unit fixed partial prostheses supported by variable-thread implants in the posterior maxilla can yield good and similar 1-year results to one-stage conventionally loaded implants.

Potentially inappropriate home medications among older patients with cardiovascular disease admitted to a cardiology service in USA

Background

The use of potentially inappropriate medications (PIMs) may pose more risks than benefits to patients and is a major factor contributing to the likelihood of serious adverse drug reactions and negative health outcomes among older patients.

Methods

A retrospective chart review was conducted in a tertiary care center in USA where home medications of the older patients were reviewed and analyzed upon hospital admission over three months, from March till May 2016. Inclusion criteria were age of 65 years and above, history of cardiovascular disease, and admission to the cardiology service. The aim of our study was to determine the frequency and factors associated with PIMs, by applying the updated Beers 2015 criteria.

Results

A total of 404 patients were included in the study and were taking a total of 4669 medications at home, an average of 11.6 ± 4.5 medications per patient. The proportion of PIMS was 20% of all medications reported, with an average of 2.4 PIM per patient, and 87.4% of patients were receiving at least one PIM. Significant association was found between use of PIMs and number of home medications, female gender, and number and types of comorbidities. Comorbidities associated with more PIMs were heart failure, atrial fibrillation/flutter, history of falls/fractures, cerebrovascular accident, and depression. The most commonly prescribed PIMs were: drugs that may exacerbate or cause syndrome of inappropriate antidiuretic hormone secretion or hyponatremia (29.7%), scheduled use of proton pump inhibitors (PPIs) > 8 weeks in non-high-risk patients (11.3%), and benzodiazepines (8.1%).

Conclusions

A high prevalence of PIMs in older patients with cardiovascular disease was observed. Provider education and detailed assessment of medication lists upon hospital admission by multidisciplinary teams can help in preventing the use of PIMs.

Development and validation of an Arabic questionnaire to assess psychosocial determinants of eating behavior among adolescents: a cross-sectional study

BACKGROUND

There is a scarcity of studies that evaluate the psychosocial determinants of eating behavior among adolescents in the Eastern Mediterranean region. The availability of such data is limited by the lack of valid culturally appropriate tools. The current study aims to develop and validate an Arabic questionnaire that measures psychosocial determinants of eating behavior among adolescents.

METHODS

A cross-sectional study was carried out to validate a five-scale questionnaire developed to measure nutrition-related knowledge, attitude, practices, and self-efficacy and social norms. Content validity was assessed by Lawshe's method, factor analysis was used to assess construct validity, and Cronbach's α was used to test internal consistency. Temporal stability was assessed by test-retest reliability. A random sample of public and private school students participated in the validation study.

RESULTS

All the five scales demonstrated excellent content validity (content validity ratio, CVR ≥0.778). Factor analysis revealed several dimensions for each scale. Cronbach's α for the identified dimensions or subscales ranged between 0.495 and 0.809 indicating acceptable internal consistency. Cronbach's α for the total scales ranged between 0.759 and 0.836. Test-retest analysis revealed good temporal stability (intraclass correlation, ICC >0.7).

CONCLUSIONS

A psychometrically valid tool to measure psychosocial determinants of eating behavior was developed. This tool can serve as a potential instrument for pretest and impact evaluation of ongoing nutrition education interventions and curricula. Based on results obtained from this tool, efficacious modifications can be instilled for nutrition policies and interventions.

Exposure to War-Related Traumatic Events, Prevalence of PTSD, and General Psychiatric Morbidity in a Civilian Population From Southern Lebanon

The South of Lebanon has experienced prolonged armed conflict. The current study aims to investigate the degree of exposure to traumatic events and prevalence of posttraumatic stress disorder (PTSD) and nonspecific general psychiatric morbidity in a civilian population from the South of Lebanon. The design was cross-sectional with random sampling. War-related traumatic events and symptoms of PTSD were assessed by the Harvard Trauma Questionnaire and general psychiatric morbidity by the General Health Questionnaire (GHQ-28). Almost all participants, 97.7%, had experienced, witnessed, or heard of a war-related traumatic event. Current PTSD prevalence was 29.3%. PTSD symptoms correlated highly with GHQ-28 symptoms, r = .73 (p < .0001). The present study indicates a need for psychological interventions in the population and studies to assess such interventions.

Distribution and predictors of emergency department charges: the case of a tertiary hospital in Lebanon

Background

As health care costs continue to increase worldwide, health care systems, and more specifically hospitals are facing continuous pressure to operate more efficiently. One service within the hospital sector whose cost structure has been modestly investigated is the Emergency Department (ED). The study aims to report on the distribution of ED resource use, as expressed in charges, and to determine predictors of/contributors to total ED charges at a major tertiary hospital in Lebanon.

Methods

The study used data extracted from the ED discharge database for visits between July 31, 2012 and July 31, 2014. Patient visit bills were reported under six major categories: solutions, pharmacy, laboratory, physicians, facility, and radiology. Characteristics of ED visits were summarized according to patient gender, age, acuity score, and disposition. Univariate and multivariate analyses were conducted with total charges as the dependent variable.

Results

Findings revealed that the professional fee (40.9 %) followed by facility fee (26.1 %) accounted for the majority of the ED charges. While greater than 80 % of visit charges went to physician and facility fee for low acuity cases, these contributed to only 52 and 54 % of the high acuity presentations where ancillary services and solutions’ contribution to the total charges increased. The total charges for males were $14 higher than females; age was a predictor of higher charges with total charges of patients greater than 60 years of age being around $113 higher than ages 0–18 after controlling for all other variables.

Conclusion

Understanding the components and determinants of ED charges is essential to developing cost-containment interventions. Institutional modeling of charging patterns can be used to offer price estimates to ED patients who request this information and ultimately help create market competition to drive down costs.

A National Study on Nurses' Exposure to Occupational Violence in Lebanon: Prevalence, Consequences and Associated Factors

Background

Healthcare institutions have commonly reported exposure of employees, particularly nurses, to high levels of occupational violence. Despite such evidence in the Middle East Region, there is a dearth of national studies that have systematically investigated this phenomenon. This study investigates the prevalence, characteristics, consequences and factors associated with nurses’ exposure to occupational violence in Lebanon.

Methods

A cross-sectional design was utilized to survey a nationally representative sample of 915 nurses registered with the Order of Nurses in Lebanon. Stratified random sampling by governorate was utilized. Individually-mailed questionnaires collected information on exposure to violence, degree of burnout and demographic/professional background. The main outcome variables were exposure to verbal abuse (never, 1–3, 4–9 and 10+ times) and physical violence (never, ever) over the past 12-months. Descriptive statistics were used to estimate prevalence of violence. Multivariable, binomial and multinomial regression models were carried out to investigate the correlates of exposure to verbal abuse and physical violence, respectively.

Results

Response rate was 64.8%. Over the last year, prevalence of nurses’ exposure to verbal abuse was 62%, (CI: 58–65%) and physical violence was 10%, (CI: 8–13%). Among respondents, 31.7% of nurses indicated likelihood to quit their jobs and 22.3% were undetermined. Furthermore, 54.1% reported high levels of emotional exhaustion and 28.8% reported high levels of depersonalization. Compared to nurses with no exposure to verbal abuse, nurses reporting high exposure had high levels of emotional exhaustion (OR:6.4; CI:1.76–23.32), depersonalization (OR:6.8; CI: 3–15) and intention to quit job (OR:3.9; CI: 1.8–8.3). They further reported absence of anti-violence policies at their institutions (OR: 3; CI: 1.5–6.3). Nurses that were ever exposed to physical violence were more likely to be males (OR: 2.2; CI: 1.1–4.3), working day and night shifts (OR: 2.8; CI: 1.4–5.5) and subject to ten or more incidents of verbal abuse per year (OR: 46.7; CI: 10.1–214).

Conclusions

An alarming two-thirds of respondents reported exposure to verbal abuse which was found to be a significant predictor of the three subscales of burnout, intention to quit and exposure to physical violence. The prevalence of exposure to physical violence is disconcerting due to its severe consequences. Policy and decision-makers are urged to use study findings for policy and practice interventions to create safe work environments conducive to nurses’ productivity and retention.

Association between payer mix and costs, revenues and profitability: a cross-sectional study of Lebanese hospitals

This study aimed to examine the association between the payer mix and the financial performance of public and private hospitals in Lebanon. The sample comprised 24 hospitals, representing the variety of hospital characteristics in Lebanon. The distribution of the payer mix revealed that the main sources of revenue were public sources (61.1%), out-of-pocket (18.4%) and private insurance (18.2%). Increases in the percentage of revenue from public sources were associated with lower total costs and revenues, but not profit margins. An inverse association was noted between increased revenue from private insurance and profitability, attributed to increased costs. Increased percentage of out of- pocket payments was associated with lower costs and higher profitability. The study provides evidence that payer mix is associated with hospital costs, revenues and profitability. This should initiate/inform discussions between public and private payers and hospitals about the level of payment and its association with hospital sector financial viability.

Validation of an Arabic Version of the GHQ-28 against the Beck Depression Inventory for Screening for Depression in War-Exposed Civilians

This study estimates the psychometric properties of the Arabic GHQ-28 against the BDI–II for screening for depression in war-exposed civilians. Two data sets collected in a civilian sample from South Lebanon were analyzed. Internal consistency in the two samples was high for the GHQ-28 (0.91 and 0.80) and the BDI–II (0.88 and 0.84). The BDI–II was significantly correlated with the GHQ-28 total score and the Depression subscale. The GHQ-28 yielded similar findings for depression cut-off scores compared to the BDI–II: for the GHQ-28 total score, a cut-off at 5/6 is recommended for detecting “severe/moderate” depression, and 8/9 for “severe” only, while from the Depression subscale analysis the recommendation was to use 8/9 as a cutoff for “severe/moderate” and 9/10 for “severe” depression. The Arabic GHQ-28 was found to be a valid instrument for screening for depression in the studied population.

Traumatic inferior epigastric vessel haemorrhage

Inferior epigastric vessel (IEV) bleeding usually results in a localised rectus sheath haematoma. This condition was thought to be uncommon and sometimes overlooked or misdiagnosed. Lately the condition has become more prevalent with life threatening bleeding which may need emergency intervention to save life. A case report of IEV bleeding following trauma in a 17-year-old male is reported. A CT scan enabled localisation of the injury site and showed signs of active bleeding. Facilities for embolization didn't exist in the hospital at the time. The bleeding was life threatening which required an emergency laparotomy.

The laparotomy confirmed the source of the bleeding as the left IEV. The offending vessel was ligated and the haematoma was evacuated. The patient recovered well and his life was saved. Bleeding from the IEV is thought to be rare and the result is usually a haematoma which can be treated conservatively. The presentation is changing and there is an increase in severity and frequency of the bleeding which can endanger life. If facilities for embolization do exist, a minimally invasive procedure is the method of choice. If on the other hand they don't exist, which is the case in many hospitals; laparotomy should be performed where there is a threat to life.

Dietary patterns in cardiovascular diseases prevention and management: review of the evidence and recommendations for primary care physicians in Lebanon

The objective of this paper is to discuss the advantages of using the dietary pattern approach in evaluating the role of diet in cardiovascular diseases (CVD) prevention and management and to report on the association between major dietary patterns and CVD risk factors among Lebanese adults. The significance of this type of research to primary care physicians is also highlighted. The dietary pattern approach overcomes the inconsistent findings of single nutrient analysis in evaluating diet-disease associations, takes into consideration the synergistic effects of nutrients, and provides culture specific recommendations. Using data from the national Nutrition and Non-Communicable Disease Risk Factor Survey, we appraised the association of dietary patterns with CVD risk factors among Lebanese adults. Two major dietary patterns were identified: Western pattern, characterized by high intake of fast food sandwiches, desserts, and carbonated beverages and the traditional Lebanese pattern, characterized by high intakes of fruits and vegetables, olives and olive oil, and traditional dishes. Only the Western pattern was associated with increased risk of obesity (abdominal obesity), hyperglycemia and the metabolic syndrome. These findings demonstrated the valuable results that can be obtained using the dietary patterns approach in evaluating the association between diet and CVD risk factors and provided evidence that this approach can be used as a tool to push for desirable dietary changes in the country.