PRevalence of the Eosinophilic Phenotype Among SeveRE asthma patients in Lebanon: results of the PREPARE study

BACKGROUND

The prevalence of eosinophilic asthma in Lebanon, one of the most severe phenotypes among severe asthma, is not known. This study aimed at determining the prevalence of the eosinophilic phenotype defined as an eosinophil count ≥ 300 cells/mm3 among severe asthma patients in Lebanon.

METHODS

The Lebanese Chapter of the PREPARE study was a national, multicenter, cross-sectional observational study. Patients aged ≥ 12 years with severe asthma were identified and prospectively enrolled during clinic visits and completed the Global Initiative for Asthma (GINA) assessment of asthma control questionnaire. Patients' health characteristics were collected from medical records and blood samples were obtained for measurement of serum IgE levels and blood eosinophils count.

RESULTS

Overall, 101 patients (with mean age of 46.3 ± 17.0 years and 73.27% females) with severe asthma were included and, among them, 37% had eosinophilic phenotype, 67.3% had atopic phenotype with IgE > 100 IU/mL and 25.7% patients had overlapping atopic and eosinophilic phenotypes. Close to 80% had late-onset asthma, beyond 12 years of age, and around 85% had at least one severe exacerbation in the 12 months prior to study enrolment. The majority of participants [64.4%] had uncontrolled asthma, 24.7% had partially controlled symptoms and 10.9% had controlled symptoms. 19.8% of participants were on chronic oral corticosteroids, 78.2% had short course treatment of corticosteroids and all were prescribed a combination of inhaled corticosteroids and long-acting beta-agonist.

CONCLUSIONS

The majority of patients with severe asthma were uncontrolled of which 37% present with an eosinophilic phenotype, which should be taken into consideration for better management of these patients in view of the novel phenotype-specific therapeutic options.

Diagnosis and management of patients with stage III non‑small cell lung cancer: A joint statement by the Lebanese Society of Medical Oncology and the Lebanese Pulmonary Society (Review)

Proper management of stage III non-small cell lung cancer (NSCLC) might result in a cure or patient long-term survival. Management should therefore be preceded by adequate and accurate diagnosis and staging, which will inform therapeutic decisions. A panel of oncologists, surgeons and pulmonologists in Lebanon convened to establish a set of recommendations to guide and unify clinical practice, in alignment with international standards of care. Whilst chest computerized tomography (CT) scanning remains a cornerstone in the discovery of a lung lesion, a positron-emission tomography (PET)/CT scan and a tumor biopsy allows for staging of the cancer and defining the resectability of the tumor(s). A multidisciplinary discussion meeting is currently widely advised for evaluating patients on a case-by-case basis, and should include at least the treating oncologist, a thoracic surgeon, a radiation oncologist and a pulmonologist, in addition to physicians from other specialties as needed. The standard of care for unresectable stage III NSCLC is concurrent chemotherapy and radiation therapy, followed by consolidation therapy with durvalumab, which should be initiated within 42 days of the last radiation dose; for resectable tumors, neoadjuvant therapy followed by surgical resection is recommended. This joint statement is based on the expertise of the physician panel, available literature and evidence governing the treatment, management and follow-up of patients with stage III NSCLC.

Comparing the efficacy and safety of formoterol/budesonide pMDI versus its mono-components and other LABA/ICS in patients with asthma

INTRODUCTION

Pressurised metered dose inhalers (pMDIs) are effective drug delivery devices prescribed in obstructive airway diseases due to their convenience, portability, ease of enabling multiple doses in a single formulation, and storage in any orientation. For the management of asthma, the fixed-dose combination of a long-acting β₂-agonist (LABA) and an inhaled corticosteroid (ICS) has been recommended by Global Initiative for Asthma guideline as a preferred treatment option for patients who are uncontrolled with only ICS doses. One of the available LABA/ICS combinations is the formoterol/budesonide (FB).

AREAS COVERED

This article systematically reviews the efficacy and safety of the FB pMDI compared with the FB dry powder inhaler (DPI), individual mono-components (formoterol and budesonide) or salmeterol/fluticasone (SF) combination in the treatment of asthma among paediatric and adult patients. PubMed was searched with the string: ''((Budesonide) AND Formoterol) AND ((((pMDI) OR MDI) OR Pressurised Metered-dose inhaler) OR Metered-dose inhaler)'', in ALL fields. Screening of all the articles was done till February 2020. We have included 24 articles from the total of 142 hits received.

CONCLUSIONS

The FB pMDI is efficacious for the long-term management of asthma in patients 6 years of age and above. It has been shown to improve lung function and asthma control, and to reduce daytime and night-time symptoms, the number of rescue medication doses and asthma exacerbations. It also showed rapid onset of bronchodilatory effect with a dose-response relationship that allows patients to utilise it as a Single Maintenance And Reliever Therapy (SMART) regimen.

Knowledge, practice pattern and attitude toward asthma management amongst physicians from Nepal, Malaysia, Lebanon, Myanmar and Morocco

OBJECTIVE

This survey aimed to understand the physicians' practice pattern and challenges faced while treating their patients with asthma in five countries-Malaysia, Nepal, Myanmar, Morocco and Lebanon.

METHODS

Questionnaire-based data was gathered from internal medicine doctors (209), general practitioners (206), chest physicians (152) and pediatricians (58) from 232 locations from across the five countries.

RESULTS

Of the 816 physicians, 374 physicians encountered at least 5 asthma patients daily. Approximately, 38% physicians always used spirometry for diagnosis and only 12% physicians always recommended Peak flow meter (PFM) for home-monitoring. Salmeterol/fluticasone (71%) followed by formoterol/budesonide (38%) were the most preferred ICS/long-acting beta₂-agonists (LABA); Salbutamol (78%) was the most preferred reliever medication. 60% physicians said >40% of their patients were apprehensive to use inhalers. 72% physicians preferred a pressurized metered-dose inhaler (pMDI) to a dry powder inhaler (DPI) with only a third of them using a spacer with the pMDI. 71% physicians believed that using similar device for controller and reliever can be beneficial to patients. Skipping medicines in absence of symptoms (64%), incorrect inhaler technique (48%) and high cost of medication (49%) were considered as major reasons for non-adherence by most physicians. Incorrect inhaler technique (66%) and nonadherence (59%) were considered the most common causes of poor asthma control.

CONCLUSIONS

There are opportunities to improve the use of diagnostic and monitoring tools for asthma. Non-adherence, incorrect inhaler technique and cost remain a challenge to achieve good asthma control. Asthma education, including correct demonstration of inhaler, can potentially help to improve inhaler adherence.

The impact of textual and pictorial warnings on tumbac (waterpipe tobacco) boxes on the motivation and intention to quit waterpipe smoking in Lebanon: a cross-sectional study

Few published studies have examined the impact of waterpipe tobacco pictorial health warnings worldwide but none of these papers assessed the motivation and intention to quit among Lebanese waterpipe smokers. To examine factors associated with the motivation and intention to quit waterpipe smoking (WS) in Lebanon, particularly the impact of textual vs. pictorial warnings on tumbac boxes. A cross-sectional study was conducted between January and May 2018, involving 520 participants. Having smokers at work (OR = 0.92) and increasing number of waterpipes per week (ORa = 0.94) were associated with decreased motivation to quit WS. Thinking that shocking images on tumbac packages would have more effect than textual warnings (ORa = 2.96) and those who would change the tumbac if the company decides to change the look of the box with shocking images about health damage (ORa = 1.98) were significantly associated with increased motivation to quit WS. Having a high motivation (ORa = 2.61), thinking that using shocking images on tumbac boxes can have more effect than textual warnings (ORa = 2.12), those who stopped smoking because of the warnings (ORa = 2.62), those who would choose pictorial warnings alone (ORa = 2.11), and both pictorial and textual warnings (ORa = 3.41) on tumbac packages were associated with higher intention to quit WS in two months. Pictorial and textual warnings on tumbac packs were associated with higher intention and motivation to stop WS. Public health education programs for this purpose seem warranted.

Development of an asthma risk factors scale (ARFS) for risk assessment asthma screening in children

BACKGROUND

The study objective was to create asthma risk factors scale (ARFS) score that would be correlated with the increased risk of asthma in Lebanese children. This scale would eventually be used both to identify children at risk and assess early diagnosis of asthma.

METHODS

A case-control study (study 1) of 1276 children (976 controls and 300 cases) and a cross-sectional study (study 2) of 1000 children were conducted using a parental questionnaire. Children aged between 3 and 16 years were screened for possible enrollment. The ARFS was created by combining the following risk factors: child's exposure to pesticides, detergent mixing, alcohol, smoking and drug intake during pregnancy and breastfeeding, the actual paternal and maternal smoking status and history of asthma, and the types of food the child consumes.

RESULTS

There was a significant increase in the risk assessment screening for asthma per 15 points increments of ARFS (p < 0.001 for trend). The score category 0-14.99 best-represented control individuals (88.8% controls), while a score higher than 45 represented asthmatic children best (98.4% asthmatics). The positive predictive value (disease positive/all positive by scale) came out as 94.02%, whereas the negative predictive value (disease negative/all negative by scale) was found to be 90.47%. These results were confirmed in the second study sample.

CONCLUSION

The ARFS is a simple and easy-to-use tool, composed of 15 questions, for the clinician risk assessment of asthma in children, taking into account the environmental exposure, parental history of asthma and dietary habits of the child. Its value for asthma diagnosis remains to be confirmed in future prospective studies, especially in children with chronic respiratory symptoms.

EPR19-072: Breast Cancer Laterality and Immunohistochemical Characteristics

Background: Differences between left and right breast cancer have been investigated in the past in terms of incidence; it is higher on the left side than on the right. This difference has ranged from 2% to 5%. However, there are no publications looking at differences in immunohistochemical characteristics between left and right sided breast cancer. This study aims to assess the incidence and age distribution as well as the following immunohistochemical characteristics: estrogen receptor (ER), progesterone receptor (PR), and epidermal growth factor 2 (HER-2). We compared the age distribution to U.S. population as well as other Arab populations. In addition we compared these and other characteristics with respect to the laterality of the breast cancer. Methods: In this pilot retrospective descriptive study, data was collected anonymously on 300 patients who presented to the Saint George Hospital University Medical Center in Beirut. They were extracted from the inpatient files with a diagnosis of breast cancer in order of presentation from 2012 until the total number of files was reached. The measured parameters included the sex of the patient, the age at diagnosis, breast cancer laterality and stage, the need for surgical treatment, and ER status, PR status, and HER-2 status as shown on the official biopsy results of the cases studied. Results: HER-2, PR-, and ER-positive receptors were found to be more frequent by 4%, 9%, and 1% on the left side as compared with the right side, respectively. These numerical differences, however, were not statistically significant. Moreover, our data analysis shows that the Lebanese population distribution of breast cancer is skewed towards a younger age when compared to the U.S., with a median age of diagnosis of 53 and 62, respectively. Finally, in term of incidence, there was a 12% increase in incidence of left side breast cancer over the right side but this value did not reach statistical significance. Conclusions: This is the first study to show the relationship between hormonal receptors and laterality of breast cancer. We concluded that there is a trend towards statistically significant differences between laterality immunohistochemical characteristics. Epidemiological relationships between the Lebanese population, the Arab population, and the U.S. population were discussed. Further researches on larger population may be needed to show some of the trends presented in this article to be statistically significant.

Validation of the St George's respiratory questionnaire and risks factors affecting the quality of life of Lebanese COPD and asthma patients

Objective: We aimed to validate the Arabic version of the St George's Respiratory Questionnaire (SGRQ) for use in Lebanese Chronic obstructive pulmonary disease (COPD) and asthma patients and to identify risk factors that might affect the quality of life in these patients. Methods: COPD (n = 90) and asthma patients (n = 124) were recruited from the outpatient clinics of the Pulmonology department of a university hospital and a medical center in Beirut. They filled out a standardized questionnaire. The total SGRQ score and the component scores (symptoms, activity and impacts) were calculated. To confirm the SGRQ validity in the Lebanese population, factor analyses were applied for the whole sample, only asthma and only COPD patients, respectively. The associations between the total SGRQ score and FEV₁% predicted, CCQ score and MRC scale were assessed. Multiple linear regression models were used to evaluate the association between the total SGRQ scores and the socio-demographics and the diseases risk factors. Results: COPD patients had a higher SGRQ total and subscales scores compared to asthma patients. A high Cronbach's alpha was found for the whole sample (0.802), only COPD patients (0.833) and only asthma patients (0.734). A significant negative correlation was found between FEV₁% predicted and the total SGRQ scores. Occupational exposure, BMI and previous waterpipe smoking were among the factors that significantly and positively influenced a higher SGRQ score. Conclusions: The Lebanese version of the SGRQ emerges as a good health-related quality of life evaluative instrument that is reasonable to be used in COPD and asthma patients in Lebanon.

Validation of the mini pediatric asthma quality of life questionnaire and identification of risk factors affecting quality of life among Lebanese children

BACKGROUND

Few studies used various scales to assess the QOL in Lebanon in general but none was specific to asthma. Our objective was to assess the asthma-related quality of life, using the mini Pediatric Asthma Quality of Life Questionnaire (PAQLQ), in Lebanese asthmatic children, check its validity compared to the original version, and identify clinical and sociodemographic risk factors that might affect these children's QOL.

METHODS

This retrospective study included 300 children aged between 7-16 years (51.6% boys and 48.4% girls). To confirm the mini-PAQLQ questionnaire construct validity in the Lebanese population, an exploratory factor analysis was launched for the 13 items of the questionnaire, using the principal component analysis technique. Cronbach's alpha was recorded for reliability analysis. A multivariate analysis linear regression was carried out, taking the QOL score as the dependent variable.

RESULTS

The correlation coefficients for factors 1 (symptoms and emotions) and 2 (activities) were similar to that of the original scale. High Cronbach's alphas were found for factor 1 (0.914), factor 2 (0.888), and the full scale (0.921). Uncontrolled asthma, the child's respiratory problems before the age of 2 years, and the presence of pets at home significantly decreased the children's asthma-related quality of life (Beta = -1.541; Beta = -6.846, and Beta = -5.364, respectively).

CONCLUSION

We were able to validate the mini-PAQLQ among the Lebanese population. The identification of risk factors, some of which are amenable to intervention, especially uncontrolled asthma, could lead to an improvement in the asthmatic children's QOL.

Association between Caregiver Exposure to Toxics during Pregnancy and Childhood-onset Asthma: A Case-control Study

The aim of this study was to evaluate the associations between caregiver-reported use of medications, alcohol, cigarette and/or waterpipe (WP), and exposure to pesticides/detergents during pregnancy with childhood-onset asthma. The study design consisted of a case-control study, conducted between December 2015 and April 2016, recruited 1503 children, aged between 3-16 years old. A questionnaire assessed the sociodemographic characteristics (age, gender, education level of both parents), the family history of asthma, and other known risk factors of asthma (heating system at home, child history of recurrent otitis, humidity in the house, child went to a daycare, smoking and drinking alcohol during pregnancy, exposure to pesticides and detergents). The multivariate analysis showed that children living in North and South Lebanon and the children living in areas where pesticides are frequently used had an increased risk of asthma (ORa=1.625, CI 1.034-2.554, p=0.035, ORa=13.65, CI 3.698-50.385; p<0.001 and ORa=3.307, CI 1.848-5.918, p<0.001 respectively). Smoking WP during pregnancy and cigarette during lactation would increase the risk of asthma in children (ORa=6.11; CI 1.244-30.008; p=0.026 and ORa=3.44; CI 1.024-11.554; p=0.046 respectively). We conclude that asthma may originate from the environmental exposure to toxics such as pesticides and tobacco (cigarettes and WP) or to alcohol and prescribed medications during pregnancy and lactation. Spreading awareness by health professionals about these preventable causes can help educate the parents and children to prevent asthma and its exacerbation.

Surfactant protein D multimerization and gene polymorphism in COPD and asthma

BACKGROUND AND OBJECTIVE

A structural single nucleotide polymorphism rs721917 in the surfactant protein D (SP-D) gene, known as Met11Thr, was reported to influence the circulating levels and degree of multimerization of SP-D and was associated with both COPD and atopy in asthma. Moreover, disease-related processes are known to degrade multimerized SP-D, however, the degree of the protein degradation in these diseases is not clarified. We aimed to determine the distribution of multimerized (high molecular weight (HMW)) and non-multimerized (low molecular weight (LMW)) species of serum SP-D and their correlation with genetic polymorphisms and presence of disease in Lebanese COPD and asthmatic patients.

METHODS

Serum SP-D levels were measured by ELISA in 88 COPD, 121 asthmatic patients and 223 controls. Randomly selected subjects were chosen for genotyping of rs721917 and multimerization studies. HMW and LMW SP-D were separated by gel permeation chromatography.

RESULTS

Serum SP-D levels were significantly increased in patients with COPD, but not in asthmatic patients, when compared to controls. Met11Thr variation strongly affected serum SP-D levels and the degree of multimerization, but was not associated with COPD and asthma in the study. Remarkably, HMW/LMW serum SP-D ratio was significantly lower in Met11/Met11 COPD and asthmatic patients compared to controls.

CONCLUSION

Collectively, non-multimerized species of serum SP-D were dominant in COPD and asthmatic patients suggesting that degradation of SP-D takes place to a significant degree in pulmonary disease. Assays that can separate SP-D proteolytic breakdown products or modified forms from naturally occurring SP-D trimers may result in optimal disease markers for pulmonary inflammatory diseases.

Predictors of past quit attempts and duration of abstinence among cigarette smokers

Objective: Despite the widespread awareness of the harms of smoking, millions continue to smoke around the world partly due to the difficulty it takes to quit smoking. Identifying the factors associated with making quit attempts is an essential pillar to reach successful quitting. The purpose of this study is to assess the factors associated with the past quit attempts and their past length of abstinence in a Lebanese sample of cigarette smokers.

Methods: This study was conducted between March 2014 and March 2015, involving 382 patients randomly chosen from 5 outpatient clinics in 5 hospitals in Lebanon. A standardized questionnaire was completed including socio-demographic characteristics, smoking behavior, chronic respiratory symptoms, Fagerstrom scale, Mondor scale, packaging perception, quitting behavior and readiness to quit ladder.

Results: Smokers who have chronic allergies (ORa = 2.45, p = 0.03), those who have ever stopped smoking for at least one month due to the warnings implemented on the packages (ORa = 4.6, p < 0.0001) and smokers with an intention to quit in 2 months (ORa = 2.49, p < 0.0001) had significantly more past quit attempts.

Results: Furthermore, longer quit attempts duration (more than 1 month) were significantly associated with low-nicotine dependent smokers (ORa = 0.56, p = 0.02), higher-motivated smokers (ORa = 1.85, p = 0.01), people with chronic allergies (ORa = 2.07, p = 0.02), smokers who have ever stopped smoking for at least one month due to the warnings (ORa = 3.72, p < 0.0001) and those with an intention to quit in 2 months (ORa = 1.98, p = 0.05).

Conclusion: The promoters of smoking cessation services should consider these factors when designing comprehensive tobacco control initiatives and in service planning.

Predictors of Readiness to Quit Stages and Intention to Quit Cigarette Smoking in 2 and 6 Months in Lebanon

BACKGROUND

We aimed at examining quitting behaviors among Lebanese cigarette smokers in order to clarify characteristics of adults who were more likely to intend to quit smoking.

STUDY DESIGN

A cross-sectional study.

METHODS

This study was conducted between March 2014 and March 2015, involving 382 patients randomly chosen from 5 outpatient clinics in 5 hospitals in Lebanon. A standardized questionnaire was completed including socio-demographic characteristics, smoking behavior, chronic respiratory symptoms, Fagerstrom scale, Mondor scale, packaging perception, quitting behavior and readiness to quit ladder.

RESULTS

40.8% of participants reported having higher stages of readiness to quit while 33% and 7.9% of them intended to quit in 2 and 6 months later, respectively. Higher stages of readiness to quit were associated with high motivation to quit smoking (ORa=1.98; P=0.007), chronic wheezing and real quit attempt duration of ≥ 1 month (ORa=2.35, P=0.020 and ORa=2.15, P=0.003, respectively). Highly motivated smokers (ORa=1.83, P=0.040), who would have changed their favorite pack due to the graphical warnings (ORa=2.11, P=0.010) and who had past quit attempt (ORa=4.39, P<0.001) had more intention to quit in 2 months. Having past quit attempts would increase the intention to quit in 6 months by 7.48 times (ORa=7.48, P=0.007).

CONCLUSIONS

Significantly higher intentions to quit cigarette smoking were associated with a higher motivation and influenced by shocking images and health related warnings on tobacco boxes. We hope our results will initiate public health educational programs and interventions to surge the intention to quit cigarette smoking as the first step of quitting.

Motivation to quit smoking and acceptability of shocking warnings on cigarette packages in Lebanon

INTRODUCTION

Health warnings on tobacco packages have been considered an essential pillar in filling the gap of knowledge and communicating the health risks of tobacco use to consumers. Our primary objective was to report the perception of smokers on the textual health warnings already appearing on tobacco packages in Lebanon versus shocking pictures about the health-related smoking consequences and to evaluate their impact on smoking behaviors and motivation.

METHODS

A pilot cross-sectional study was undertaken between 2013 and 2015 in five hospitals in Lebanon. Participants answered a questionnaire inquiring about sociodemographic characteristics, chronic respiratory symptoms, smoking behavior and motivation to quit smoking. Only-text warning versus shocking pictures was shown to the smokers during the interview.

RESULTS

Exactly 66% of the participants reported that they thought shocking pictorial warnings would hypothetically be more effective tools to reduce/quit tobacco consumption compared to only textual warnings. Also, 31.9% of the smokers who were motivated to stop smoking reported that they actually had stopped smoking for at least 1 month secondary to the textual warnings effects. A higher motivation to quit cigarette smoking was seen among the following groups of smokers: males (odds ratio [OR] =1.8, P=0.02), who had stopped smoking for at least 1 month during the last year due to textual warning (OR =2.79, P<0.001), who considered it very important to report health warning on cigarette packs (OR =1.92, P=0.01), who had chronic expectoration (OR =1.81, P=0.06) and who would change their favorite cigarette pack if they found shocking images on the pack (OR =1.95, P=0.004).

CONCLUSION

Low-dependent smokers and highly motivated to quit smokers appeared to be more hypothetically susceptible to shocking pictorial warnings. Motivation to quit was associated with sensitivity to warnings, but not with the presence of all chronic respiratory symptoms.

Maternal waterpipe smoke exposure and the risk of asthma and allergic diseases in childhood: A post hoc analysis

INTRODUCTION

This analysis was conducted with the objective of evaluating association between waterpipe passive smoking exposure and asthma, and allergies among Lebanese children.

MATERIAL AND METHODS

Data were taken from a crosssectional study on children from public and private schools. A sample of 22 schools participated in the study, where standardized written core questionnaires were distributed. From 5 to 12-year-old students filled in the questionnaires at home, while 13-14-year-old students filled it in in the class. In total, 5522 children were evaluated for the prevalence of asthma, allergic rhinitis and atopic eczema, and their associated factors, including waterpipe exposure due to parents' smoking.

RESULTS

The descriptive results of parental smoking were, as follows: among mothers: 1609 (29%) mothers smoked cigarettes, 385 (7%) smoked waterpipe and 98 (1.8%) smoked both; among fathers: 2449 (44.2%) smoked cigarettes, 573 (10.3%) smoked waterpipe and 197 (3.5%) smoked both. Maternal waterpipe smoking was significantly and moderately associated with allergic diseases (p < 0.001; ORa = 1.71), including probable asthma, rhinitis and dermatitis (p < 0.001 for all). Quite on the opposite, father's waterpipe smoking was not associated with any of the diseases. Parental cigarette smoking demonstrated some positive effects: father's cigarette smoking did not show association with dermatitis or asthma diagnosed by a physician, while mother's cigarette smoking showed a positive association only with probable asthma. Moreover, no interactions between cigarette and waterpipe smoking were observed.

CONCLUSIONS

Maternal waterpipe smoking should be regarded as a high risk behavior; however, additional studies are necessary to confirm this finding.

Validation of asthma control questionnaire and risk factors affecting uncontrolled asthma among the Lebanese children's population

OBJECTIVES

To validate the Arabic version of the Asthma Control Test (ACT) in asthmatic children in Lebanon and identify risk factors that might affect asthma control in these children.

METHODS

This study, conducted between December 2015 and April 2016, included 300 children.

RESULTS

A high Cronbach's alpha was found for the full scale (0.959). The correlation factors between each item of the ACT scale and the whole scale ranged between 0.710 and 0.775(p < 0.001 for all items). Low mother's educational level as well as the history of asthma in the mother and the father would significantly increase the risk of uncontrolled asthma (p = 0.001; Beta = 1.862; p < 0.001; Beta = 3.534; p < 0.001; Beta = 1.885respectively). Cigarette smoking during breastfeeding and waterpipe smoking by the mother during pregnancy were both significantly associated with uncontrolled asthma (p = 0.005; Beta = 2.105 and p = 0.041; Beta = 2.325 respectively). The high mother's level of education was significantly associated with more asthma control (p = 0.008; Beta = -0.715).

CONCLUSION

The Arabic version of the asthma control questionnaire is a valid tool to use in pediatric patients in the Lebanese population to assess asthma control. Waterpipe smoking during pregnancy and cigarette smoking during breastfeeding, as well as the lower education level are risk factors for uncontrolled asthma. Spreading awareness among health care professionals, as well as reinforcing health education seem to be an important step toward a better asthma control.

Surfactant protein D, a clinical biomarker for chronic obstructive pulmonary disease with excellent discriminant values

Biological markers can help to better identify a disease or refine its diagnosis. In the present study, the association between surfactant protein D (SP-D) and chronic obstructive pulmonary disease (COPD) was studied among subjects consulting for respiratory diseases or symptoms and was compared with C-reactive protein (CRP) and fibrinogen. A further aim of this study was to identify the optimal cut-off point of SP-D able to discriminate COPD patients. A case-control study including 90 COPD patients, 124 asthma patients and 180 controls was conducted. Standardized questionnaires were administered and lung function tests were performed. Biological markers were measured in blood samples according to standardized procedures. The association between SP-D and COPD was investigated using logistic regression models. Receiver-operating characteristic curves were used for threshold identification. SP-D levels above the median value were positively associated with COPD [adjusted odds ratio (OR)=3.86, 95% confidence interval (CI): 1.51–9.85, P=0.005). No associations with COPD or asthma were found for CRP or fibrinogen levels. Scores for COPD diagnosis in all COPD patients or ever-smoker COPD patients were identified (sensitivity, 76.4 and 77.8%; specificity, 89.3 and 88.5%, respectively). The results indicate that SP-D can differentiate COPD from other respiratory symptoms or diseases. Used with socio-demographic characteristics and respiratory symptoms, SP-D is able to discriminate COPD patients from controls, particularly among smokers.

[Asthma, indoor and outdoor air pollution: A pilot study in Lebanese school teenagers]

INTRODUCTION

Many studies have demonstrated that outdoor pollution might exacerbate respiratory symptoms and childhood asthma. Our objective was to evaluate the relationship between asthma and outdoor and indoor pollution.

METHODS

We undertook a survey in May-June 2012 about schoolchildren aged 12-19 years in six Lebanese schools. This combined the International Study of Asthma and Allergies in Childhood (ISAAC) standardized questionnaire with other questions addressing outdoor and indoor exposure.

RESULTS

Among 717 subjects (response rate 71.7%), 4.5% had physician-diagnosed asthma, 34.7% had probable asthma and 60.8% were asymptomatic. Exposure to indoor contaminants was positively associated to asthma. The risk for asthma was higher in those residing near heavy road traffic (ORa=4.30 [95% CI 1.45-12.71], P<0.05), those previously exposed to fire (ORa=1.84 [95% CI 1.01-3.36]), and those exposed to smog (ORa=4.15 [95% CI 1.42-12.12]). Airing the house in the morning or in case of indoor smoking had a protective effect against asthma.

CONCLUSION

These results suggest that the risks of asthma or having respiratory symptoms are not only related to indoor pollution but also to outdoor pollution especially from road traffic.

Hyperreactive airway disease in adults: data from a national study in Lebanon

BACKGROUND

Asthma and hyperreactive airway (HRA) disease are a major cause of health resource utilization and poor quality of life worldwide; its prevalence in adults may widely vary according to the definition used. It is mainly a childhood disease, but its natural history till adulthood is not well known. This is due to other confounding factors such as smoking and environmental factors that may lead to misdiagnose asthma as chronic obstructive pulmonary disease. Correct and timely diagnosis of asthma and HRA is important because it can be treated successfully and affected individuals may achieve good control of their disease.

OBJECTIVE

To evaluate the prevalence of asthma and HRA in Lebanese adults, their symptoms and predictors.

METHODS

A cross-sectional study using a multistage cluster sample was carried out in Lebanon, between October 2009 and September 2010.Lebanese residents aged 40 and above participated to the study; a post-bronchodilator spirometry was performed to confirm diagnosis.

RESULTS

Out of 2201 individuals, 218 (99%) were considered to have HRA. The following factors were found associated with HRA in the Lebanese population: Northern (ORa: 3.54) and Bekaa Plain (ORa: 2.44)] versus other regions; occupational exposure to toxic gases and fumes (ORa: 2.08); heating home with wood (ORa: 1.75); having a family history of chronic respiratory disease (ORa: 2.19), a history of childhood lung problem (ORa: 5.53), and father smoking during childhood (ORa: 1.47). Added to these factors, HRA was also predicted by female gender (ORa: 1.81); lower education (ORa: 120); older age (ORa: 1.28) and low birth weight (ORa: 3.14).

CONCLUSION

This is the first epidemiological study in Lebanon that determined physician diagnosed asthma prevalence and hyperreactive airway disease and their associated factors among Lebanese adults. It also provides useful contributions that local health organizations may use for national programming and a foundation for health researchers to pursue further study in asthma research. Public awareness about the increased risk of asthma associated with heating homes with wood and exposure to passive smoking should be raised; Lebanese policy makers should also generate higher efforts to implement and reinforce the smoking ban law in public places.

Risk perception, motives and behaviours in university students

Risky behaviours among young people are relatively frequent, with several motives and attitudes lying behind. Our objective was to evaluate the role of risk perception, attractiveness and motives for risk behaviour taking among university students in Lebanon. A cross-sectional study was carried out using a proportionate cluster sample of Lebanese students in public and private universities. Items of risk intake and perception scale, attractiveness of risky behaviours, and motives for risky behaviours were assessed, in addition to cigarette and waterpipe smoking and dependence, alcohol problematic consumption and mental distress scale. After verifying the validity of scales and reliability in the university students' population, we found that risk perception was associated with lower risk intake, while risk attractiveness was a driver for it. Moreover, motives differed in their driving of risky behaviour, a particular point was that women indicated more goal achievement objectives, the latter concept was associated with lower risk taking. University students in Lebanon, women in particular, demonstrated wiser behaviour and may benefit from heath education programme to increase their awareness about risky behaviours. Identifying other personal, environmental, social and psychological predictors may also be important to improve effectiveness of these programmes.

Waterpipe dependence in university students and effect of normative beliefs: a cross-sectional study

OBJECTIVES

The objective of this study was to measure the correlates, including normative beliefs, associated with waterpipe (WP) and cigarette smoking prevalence and dependence.

SETTING

A cross-sectional study was carried out using a proportionate cluster sample of Lebanese students in 17 public and private universities.

PARTICIPANTS

Of the 4900 distributed questionnaires, 3384 (69.1%) were returned to the field worker. All available students during break times were approached, with no exclusion criteria.

PRIMARY AND SECONDARY OUTCOME MEASURES

sociodemographic variables, detailed active and passive smoking, in addition to items of the tobacco dependence scales were all evaluated.

RESULTS

Correlates to WP smoking were studying in a private university (adjusted OR, aOR=1.50 (1.26 to 1.79); p<0.001) and ever smoking cigarettes (aOR=1.80(1.44 to 2.26); p<0.001); friends' and societal influence were found on smoking behaviour and dependence. Although the role of parents was not visible in decreasing the risk of smoking WP, their protective influence seemed more important on WP dependence (β=-1.09(-1.79 to -0.28); p<0.001), a behaviour that is considered more deleterious for health. Parents' and friends' disagreement with smoking had a protective effect on cigarette smoking and dependence (aOR<1; p<0.01), while thinking that idols and successful people smoke increased the risk of both cigarette smoking and dependence (aOR>1; p<0.01).

CONCLUSIONS

In conclusion, WP smoking and dependence are influenced by parents' and friends' opinions, and idols' smoking status. Future research is necessary to further improve our understanding of motives for WP smoking and dependence.

Lung cancer correlates in Lebanese adults: a pilot case--control study

BACKGROUND

Lung cancer is one of the most prevalent types of cancers. However, there are no epidemiological studies concerning lung cancer and its risk factors in Lebanon. This study was carried out to determine the association between lung cancer and its most common risk factors in a sample of the Lebanese population.

METHODS

A hospital-based case-control study was conducted. Patients were recruited in a tertiary health care center. A questionnaire in Arabic was designed to assess the possible risk factors for lung cancer.

RESULTS

For females, cigarette smoking (ORa=9.76) and using fuel for heating (ORa=9.12) were found to be the main risk factors for lung cancer; for males, cigarette smoking (ORa=156.98), living near an electricity generator (ORa=13.26), consuming low quantities of fruits and vegetables (ORa=10.54) and a family history of cancer (ORa=8.75) were associated with lung cancer. Waterpipe smoking was significantly correlated with lung cancer in the bivariate analysis.

CONCLUSION

In this pilot study, it was found that in addition to smoking, outdoor and indoor pollution factors were potential risk factors of lung cancer. Additional studies would be necessary to confirm these findings.

Waterpipe smoking and dependence are associated with chronic bronchitis: a case-control study in Lebanon

Waterpipe smoking and its association with chronic bronchitis has not been assessed in Lebanon. This case-control study in Beirut in 2009/2010 evaluated this relationship: 274 cases of chronic bronchitis and 559 controls without the condition aged > or = 40 years were enrolled. Data were collected by questionnaire on: sociodemographic characteristics, respiratory symptoms, smoking (waterpipe and cigarette) and nicotine dependence. ANOVA, Student, Kruskal-Wallis, chi-squared and Fisher exact tests were used when applicable and logistic regression analysis was carried out. Previous waterpipe smoking (OR = 6.4), previous mixed smoking (OR = 38.03) and current mixed smoking (OR = 7.68) were significantly associated with chronic bronchitis (P < 0.001 for all) but current exclusive waterpipe smokingwas not (OR = 1.87, 95% CI: 0.74-4.72). Current waterpipe dependence was significantly associated with chronic bronchitis (OR = 3.74, P < 0.001). After adjustment for covariates/confounders, ever waterpipe smoking > 20 WP-years (P < 0.001) was significantly associated with chronic bronchitis.

Cigarette smokers' profile in Lebanese adults

BACKGROUND

The objective of this study was to describe cigarette smoking prevalence among adults in Lebanon and to evaluate the profile of light cigarette smokers compared to never and heavy smokers.

METHODS

Data were taken from a cross-sectional study carried out from October 2009 to September 2010, using a multistage cluster sampling all over Lebanon. Lebanese residents aged 40 years and above were enrolled in the study with no exclusion criteria. After an oral informed consent, subjects answered a questionnaire, including detailed smoking history and cigarette dependence. SPSS version 17.0 was used for data analysis.

RESULTS

Out of 2201 individuals, 1320 (60.0%) had ever smoked cigarettes, out of whom 10.1% were light cigarette smokers. The adjusted odds ratio estimate of cigarette smoking was 3.08 for males compared to females (P<0.001), 1.13 for lower education (P=0.016), 1.87 and 3.12 for retired and jobless compared to working (P=0.001 and P<0.001) respectively, 1.17 for older age (P<0.001), 1.68 for presence versus absence of a family history of chronic respiratory disease (P<0.001), and 5.27 and 1.99 for presence compared to absence of at least one smoker at home (P<0.001) and at work (P<0.001) respectively.

CONCLUSION

This is the first epidemiological study in Lebanon that determined cigarette smoking prevalence at the national level. In Lebanon, males of the older generation seem to have higher smoking prevalence and dosing.

Waterpipe Smoking and Dependence are Associated with Chronic Obstructive Pulmonary Disease: A Case-Control Study

Introduction:

Waterpipe smoking gained popularity during recent years. Although waterpipe smoking exposes people to the same noxious substances found in cigarettes, popular belief considers it harmless. Our objective was to evaluate the association between waterpipe smoking and dependence, and COPD.

Methods:

We conducted a case-control study in two tertiary care hospitals. Cases were included if diagnosed as COPD by a pulmonologist and confirmed by post-bronchodilator FEV1/FVC<0.7; controls were included if free of any respiratory disease or symptom. After oral consent, a standardized questionnaire was administered and spirometry results were collected.

Results:

211 COPD cases and 527 controls were studied. In previous smokers, any smoking type was associated with COPD. The ORs were 29.0[14.3-58.8] (p<0.001) for previous cigarette smoking, 11.7[4.4-31.2] (p<0.001) for previous waterpipe smoking, and 44.1[16.3-4.4] (p<0.001) for previous mixed smoking. In current smokers, the ORs were 20.5[10.2-41.2] (p<0.001) for cigarette smoking, 1.8[0.5-5.9] (p=0.299) for waterpipe smoking, and 9.4[3.81-23.0] (p<0.001) for mixed smoking. Nevertheless, we found in waterpipe current smokers, an OR=8.9[3.9-20.7] (p<0.001) for the association between dependence evaluated by LWDS-11 scale, and COPD. These results were confirmed by stratified and multivariate analysis, after adjustment for cigarette smoking and confounding variables. A cumulative smoking of one waterpipe per week for 20years (or its equivalent) was predictive of higher risk of COPD.

Discussion:

Whereas evidence showing harmful effects of waterpipe smoking is sparse, this study showed a high OR between the risk of developing COPD and being an ex-smoker of waterpipe, or a current waterpipe dependent individual. Additional studies are necessary to confirm our results.

Exposure to outdoor air pollution and chronic bronchitis in adults: a case-control study

BACKGROUND

Although Lebanon is a highly polluted country, so far no study has specifically been designed to assess the association between outdoor air pollution and chronic bronchitis in this country.

OBJECTIVE

To assess the association between exposure to outdoor air pollution and chronic bronchitis in Lebanon.

METHODS

A pilot case-control study was conducted in two tertiary care hospitals. Cases consisted of patients diagnosed with chronic bronchitis by a pulmonologist and those epidemiologically confirmed. Controls included individuals free of any respiratory signs or symptoms. After obtaining informed consent, a standardized questionnaire was administered.

RESULTS

Bivariate, stratified (over smoking status and gender) and multivariate analyses revealed that passive smoking at home (ORa: 2.56, 95% CI: 1.73-3.80) and at work (ORa: 1.89, 95% CI: 1.13-3.17); older age (ORa: 1.75, 95% CI: 1.55-2.39); lower education (ORa: 1.44, 95% CI: 1.21-1.72); living close to a busy road (ORa: 1.95, 95% CI: 1.31-2.89) and to a local power plant (ORa: 1.62, 95% CI: 1.07-2.45); and heating home by hot air conditioning (ORa: 1.85, 95% CI: 1.00-3.43) were moderately associated with chronic bronchitis; an inverse association was found with heating home electrically (ORa: 0.58, 95% CI: 0.39-0.85). A positive dose-effect relationship was observed in those living close to a busy road and to a local diesel exhaust source.

CONCLUSION

Chronic bronchitis is associated with outdoor air pollution.

Could symptoms and risk factors diagnose COPD? Development of a Diagnosis Score for COPD

Background:

Diagnosing chronic obstructive pulmonary disease (COPD) without spirometry is still a challenge. Our objective in this study was to develop a scale for diagnosis of COPD.

Methods:

Data were taken from a cross-sectional epidemiological study. After reducing chronic respiratory symptoms, a logistic regression was used to select risk factors for and symptoms of COPD. The rounded coefficients generated a Diagnosis Score for COPD (DS-COPD), which was dichotomized and differentiated between COPD and other individuals with respiratory symptoms.

Results:

We constructed a tool for COPD diagnosis with good properties, comprising 12 items. The area under the curve was 0.849; the positive predictive value was 76% if the DS-COPD was >20 and the negative predictive value was 97% if the DS-COPD was <10. A DS-COPD of 10–19 represented a zone mostly suggestive of no COPD (77%). The score was also inversely correlated with forced expiratory volume in 1 second/forced vital capacity.

Conclusion:

In this study, a tool for diagnosis of COPD was constructed with good properties for use in the epidemiological setting, mainly in cases of low or high scoring. It would be of particular interest in the primary care setting, where spirometry may not be available. Prospective studies and application in clinical settings would be necessary to validate this scale further.

Correlates of COPD and chronic bronchitis in nonsmokers: data from a cross-sectional study

Purpose

Our objective was to assess the prevalence of chronic bronchitis and chronic obstructive pulmonary disease (COPD) and their correlates among a Lebanese nonsmoker group.

Material and methods

A cross-sectional study was conducted between October 2009 and September 2010, using a multistage cluster sample throughout Lebanon including Lebanese residents aged 40 years and above with no exclusion criteria. Pre- and postbronchodilator spirometry measurements were performed and carbon monoxide level was measured in exhaled air. COPD was defined and classified according to the Global Initiative for Chronic Obstructive Lung Disease guidelines or according to the lower limit of normal (forced expiratory volume in 1 second/forced vital capacity postbronchodilator < 5th percentile of the healthy population having the same age and sex). Chronic bronchitis was defined by the declaration of morning cough and expectorations for more than 3 months a year over more than 2 years in individuals with normal spirometry.

Results

Out of 2201 individuals, 732 were never-smokers: 25 (3.4%) of them had COPD, and 86 (11.75%) fulfilled the definition of chronic bronchitis. Correlates of COPD included a childhood respiratory disease, house heated by diesel, and older age. On the other hand, correlates of chronic bronchitis included childhood respiratory diseases, living in southern Lebanon versus other regions, heating home by gas, older age, number of smokers at work, and lower height.

Conclusion

A substantial percentage of the nonsmoking population may exhibit chronic bronchitis or COPD. The significant correlates mentioned above should be taken into consideration in order to reduce the risk of developing such chronic and debilitating respiratory diseases.

Lower extremity venous thrombosis in patients younger than 50 years of age

Aim

Lower extremity deep venous thrombosis in the young adult is uncommon and has not been well studied in the literature. The aim of this study is to define risk factors for deep venous thrombosis among patients younger than 50 years of age, to compare them with a control group, and to suggest recommendations for the management and treatment of venous thrombosis in this particular group of patients.

Methods

From January 2003 to January 2011, 66 consecutive Lebanese patients (29 males and 37 females) younger than 50 years, diagnosed in an academic tertiary-care center with lower extremity deep venous thrombosis by color flow duplex scan, were retrospectively reviewed. Their age varied between 21 and 50 years (mean 38.7 years). The control group included 217 patients (86 males and 131 females) older than 50 years (range: 50–96 years; mean 72.9 years).

Results

The most commonly reported risk factors in the younger age group were inherited thrombophilia (46.9% compared with 13.8% in the control group; P < 0.001), pregnancy (18.2% compared with 0.5%; P < 0.001), treatment with estrogen drugs (13.6% compared with 2.3%; P = 0.001), and family history of venous thromboembolism (9.1% compared with 3.8%; P = 0.084).

Conclusion

Inherited thrombophilia is the most commonly observed risk factor among patients younger than 50 years, with a prevalence of three times more than the control group. Young adults should be screened for thrombophilia even in the presence of transient acquired risk factors. Pregnancy and treatment with estrogen drugs essentially when associated with inherited thrombophilia represent a frequent cause of venous thrombosis among young female patients. Inferior vena cava abnormalities should be excluded in young patients with spontaneous proximal venous thrombosis especially when recurrent venous thrombosis or resistance to anticoagulation are observed.

Acquired and genetic risk factors for deep vein thrombosis of lower extremities among Lebanese patients

AIM

Venous thrombosis results from the interaction of environmental and genetic risk factors. These factors vary according to the ethnic and geographic distribution of the populations. The aim of this study is to define the role of acquired and genetic risk factors for venous thrombosis of lower extremities among Lebanese patients assessed in a university hospital and to discuss them according to the international literature.

MATERIAL AND METHODS

From January 2005 to January 2010, 166 patients (72 males and 94 females) were diagnosed with lower extremity deep vein thrombosis. Mean age was 67 years (range: 25 to 96 years).

RESULTS

The most frequently reported acquired risk factors for venous thrombosis in this study were advanced age, obesity, history of venous thromboembolism, immobilization, surgery, varicose veins and malignancy. Screening for prothrombotic genetic abnormalities was requested in patients with conditions highly suggestive of hypercoagulation state such as young patients, patients with spontaneous, recurrent or extensive venous thrombosis, patients with family history, oral contraceptives, air travel and pregnancy. All the 45 patients (27.1%) tested for thrombophilia were positive and were carriers for factors V-Leiden (17.4%), MTHFR C 677 T (16.8%), MTHFR A 1298 C (4.8%), II G 20210 A (1.8%) and V H 1299 R (1.2%) mutation. Twelve patients (7.2%) had increased homocysteine level.

CONCLUSION

Advanced age is the most common risk factor for venous thrombosis in these series. Thrombophilia is the second most frequently observed risk factor and is related to the high prevalence of factor V-Leiden and MTHFR C 677 T mutation among the Lebanese population.

Chronic obstructive pulmonary disease prevalence in Lebanon: a cross-sectional descriptive study

Background

Chronic obstructive pulmonary disease (COPD) continues to increase worldwide. The objective of this study was to determine the prevalence of COPD in Lebanese adults.

Methods

A cross-sectional study was carried out using a multistage cluster sample from all over Lebanon. Residents aged 40 years and over were enrolled. Subjects underwent baseline spirometry and answered a questionnaire. After an albuterol + ipratropium bromide bronchodilator, a posttest was performed.

Results

Of 2201 individuals, only 33.3% had never smoked. The prevalence of COPD by the Global Initiative for Chronic Obstructive Lung Disease definition, was 9.7% (95% confidence interval [CI]: 8.5%–10.9%). According to the 5% lower limit of normal definition of COPD, the prevalence was 12.5% (95% CI: 11.2%–13.9%). A total of 20.2% were already diagnosed by a physician. No differences in symptoms across stages of COPD were found, but there was a significant trend for a higher number of visits to the emergency room and to the doctor (P < 0.001), and a higher number of hospitalizations (P < 0.001). Older individuals had an increased risk of COPD (adjusted odds ratio [OR_a] = 1.05); so did “ever” cigarette smokers (OR_a = 4.88) and water-pipe smokers (OR_a = 2.53).

Conclusion

This is the first epidemiological study in Lebanon that determined COPD prevalence and the link with water-pipe smoking.

Value of venous color flow duplex scan as initial screening test for geriatric inpatients with clinically suspected pulmonary embolism

AIM

The contribution of lower extremity venous duplex scan to the diagnostic strategy for pulmonary embolism has been demonstrated by many authors. However, the positive diagnostic value of this noninvasive test in clinically suspected pulmonary embolism is not very high (10% - 18%). Since thromboembolic risks increase considerably in hospitalized patients with advanced age, this study aims to determine the importance of lower extremity venous color flow duplex scan in this particular subgroup of patients with clinically suspected pulmonary embolism. The effects of clinical presentation and risk factors on the results of duplex scan have been also studied.

METHODS

Between July 2007 and January 2010, 95 consecutive Lebanese geriatric (≥ 60 years of age) inpatients with clinically suspected pulmonary embolism assessed in an academic tertiary-care center for complete lower extremity venous color flow duplex scan were retrospectively reviewed. Age varied between 60 and 96 years (mean, 79.9 years). Forty patients were males and 55 females. Absence of compressibility was the most important criteria for detecting acute venous thrombosis.

RESULTS

Out of 95 patients, 33 patients (34.7%) were diagnosed with recent deep venous thrombosis of lower extremities (14 proximal and 19 distal) using complete venous ultrasound. Nine of these 33 patients (27.2%) had a history of venous thromboembolism and eleven (33.3%) presented with edema of lower extremities. A total of 28 patients (84.8%) with positive duplex scan had associated risk factors for venous thromboembolism.

CONCLUSION

Lower extremity venous color flow duplex scan appears to be a reasonable initial screening test in the diagnostic algorithm of pulmonary embolism in geriatric inpatients with clinically suspected pulmonary embolism. This is particularly true in patients with a history of venous thromboembolism, in patients with a clinical presentation suggesting venous thrombosis, in uremic patients and in patients with altered general and mental status who are not candidates for chest computed tomography.

The AVAIL ME Extension: a multinational Middle Eastern survey of venous thromboembolism risk and prophylaxis

BACKGROUND

Venous thromboembolism (VTE) is a major worldwide problem.

OBJECTIVES

The primary objectives of this survey were to identify patients at risk for VTE, to define the rate of patients receiving appropriate VTE prophylaxis and to examine the frequency of the presence of guidelines and their application.

PATIENTS AND METHODS

Ten countries, 101 hospitals and a total of 4983 patients were included in this multinational cross-sectional survey. Standardized case report forms were filled out by trained individuals on one predefined day. Risks were categorized according to the Caprini Risk Assessment Model. Logistic regressions were carried out to assess factors that determined VTE prophylaxis.

RESULTS

Of 4983 patients, 3368 (68%) and 1615 (32%) were surgical and medical, respectively. Seven hundred and seventy-two (15.5%) were considered to be at low risk, 1001 (20%) at moderate risk, 1289 (26%) at high risk and 1921 (38.5%) at very high risk for VTE. Of 3575 (72%) patients who were eligible to receive VTE prophylaxis, 2747 (77%) received any drug prophylaxis. Among these patients 720/1056 (68%) and 2027/2519 (80%) were medical and surgical patients, respectively. The overall compliance with ACCP guidelines was 38%, being 24% for medical patients and 44% for surgical patients.

CONCLUSIONS

The results of this large multinational survey, although indicating overall improvement in VTE prophylaxis, identify a considerable number of patients who either did not receive any VTE prophylaxis or received it inappropriately. Although more medical patients were at risk for VTE, they were given prophylaxis less frequently than surgical patients. Concordance with VTE prophylaxis guidelines was higher in surgical patients, but overall application of these tools was unacceptably low.

Water-pipe (narguile) smokers in Lebanon: a pilot study

We carried out a comparative study to assess the demographic and social characteristics of water pipe (WP) smokers, the association with cigarette smoking and chronic respiratory diseases and the dependence profile on 4 groups: exclusive WP smokers, exclusive cigarette smokers, mixed smokers and absolute non-smokers. Cigarette smoking was statistically significantly higher in WP smokers than non-WP smokers; 36.5% of exclusive WP smokers smoked > or =7 WPs/week. Chronic respiratory disease and chronic bronchitis were reported more frequently in exclusive WP smokers than absolute non-smokers. WP smoking seems to be as great a risk factor as cigarette smoking for chronic respiratory disease.

Risk factors for asthma and allergic diseases in school children across Lebanon

Introduction:

Childhood asthma is one of important diseases of childhood. There is no known prevalence of asthma and allergic diseases in Lebanon. This study was conducted with a secondary objective of finding the odds of exposure to asthma, allergic rhinitis and eczema potential risk factors in Lebanese children.

Material and methods:

It is a cross-sectional study on children in public and private schools. A sample of 22 schools participated, where standardized written core questionnaires were distributed. 5–12 year old students completed the questionnaires at home, while 13–14 year old students filled it in class.

Results:

5522 children were evaluated for asthma, allergic rhinitis and atopic eczema prevalence and their associated factors. These diseases seem to be similarly affected by parental respiratory problems, parental smoking, infancy gastroesophageal reflux, recurrent otitis, and previous pertussis. Humidity on the bedroom walls is associated with both asthma and allergic rhinitis, a spongy pillow with both allergic rhinitis and eczema, animal possession with asthma, and noncotton mattress with atopic eczema. The adjusted odds ratios for significant associations varied between 1.25 and 3 (0.0001 < p-value < 0.01).

Conclusion:

These factors are preventable, thus permitting a possible reduction of the prevalence of these diseases.

Waterpipe smoking: construction and validation of the Lebanon Waterpipe Dependence Scale (LWDS-11)

Waterpipe smoking is becoming fashionable in Lebanon, but no studies have studied nicotine dependence related to waterpipe smoking. A score was constructed from 21 items and subsequently submitted to two factor analyses, which led to the extraction of four factors. Reliability and test-retest reproducibility were measured. Convergent construct validity and discriminant validity also were assessed for different smokers' samples. The Lebanon Waterpipe Dependence Scale-11 (LWDS-11) was composed of four subscales, the first representing nicotine dependence, the second negative reinforcement, the third psychological craving, and the fourth positive reinforcement. Internal consistency and test-retest reproducibility were adequate, and the subscales correlated adequately with measurements of nicotine metabolites, exhaled carbon monoxide levels, and the frequency of waterpipe smoking. The LWDS-11 discriminated between mild, moderate, and heavy waterpipe smokers, based on a threshold score of 10. Results were biologically and psychologically sound. This is the first scale to characterize waterpipe dependence. With further improvement and confirmation, it could become a useful clinical and epidemiological tool.

Asthma, allergic rhinitis and eczema in 5-12-year-old school children across Lebanon

OBJECTIVES

To determine the prevalence of asthma, allergic rhinitis and eczema in Lebanese children.

STUDY DESIGN

Descriptive cross-sectional study on children in public and private schools in Lebanon.

METHODS

Standardized written questionnaires were distributed to 5-12-year-old students at 22 schools.

RESULTS

In total, 3909 individuals were analysed. The prevalence of diagnosed asthma (4.8%) was low, while the prevalence of allergic rhinitis was 21.2% and that of eczema was 11.8%. Marked variations and differences were found across the governates in Lebanon, with the lowest prevalence of diagnosed asthma (1.8%) in Bekaa and the highest prevalence in Beirut (11.6%).

CONCLUSION

Asthma symptoms, rhinitis and eczema have medium prevalence in Lebanon compared with worldwide data. Compared with other countries in the Eastern Mediterranean Region, the prevalence of 12 months of wheezing, night cough and wheezing on exercise were highest in Lebanon, but were much lower compared with English-speaking countries. Further studies are needed to understand the environmental, climatic and socio-economic causes of these discrepancies.

Saliva cotinine and exhaled carbon monoxide levels in natural environment waterpipe smokers

The purpose of this study is to evaluate the variations in exhaled CO and saliva cotinine in natural environment waterpipe smokers and compare them with cigarette smokers and absolute nonsmokers. Three groups were included in the study: nonsmokers (n = 20), waterpipe smokers (n = 15), and cigarette smokers (n = 20). A questionnaire was completed for each participant, exhaled CO was measured before and after waterpipe or cigarette smoking, and saliva cotinine was measured immediately after. We excluded from our study mixed smokers of both waterpipe and cigarettes. Mean values of saliva cotinine in waterpipe and cigarette smokers were very close: 77.8 ng/ml (SD = 110.4) and 87.1 (SD = 82.7) respectively. The weight and height of the persons as well as the size of the waterpipe bottle affected saliva cotinine. However, in waterpipe smokers, CO increased by 300% after 1 h of smoking, while in cigarette smokers, it only increased by 60%. In nonsmokers, exhaled CO was similar to environmental CO (10.2 ppm). The results of our study confirm that waterpipe device water does not filter nicotine and that the smoker him- or herself, by the frequency and the depth of inhalation, controls smoke inhalation. Like cigarette smokers, waterpipe smokers are exposed to harmful substances, such as CO, which was found to be quite high. The levels of expired CO and salivary cotinine could be good tools to detect exposure to waterpipe smoking.

Symptoms, severity and asthma control in 5-14 y-old Lebanon school children

BACKGROUND

This study addressed symptoms' profile, severity and determinants of asthma control in school-aged patients (5-14 y) across Lebanon.

METHODS

It is a cross-sectional study, applied on school children with physician-diagnosed asthma (PDA), divided into two groups: those who were on controllers (C+) and those who were not (NC).

RESULTS

Out of 5544 children, 275 (4.96%) had PDA. The C+ group (32.7%) had higher mother's education than the NC group (45.9%) (p = 0.037). NC children were more frequently found in public versus private schools (p = 0.0001). Higher frequencies of regular visits to the doctor were noted in the C+ compared to NC group. In C+ group, 90% were on reliever and controller, and 10% just on one controller. A trend for more severity in the C+ group was noted compared to the NC group. An impact of asthma on daily activities was reported by 40% in the C+ group versus 34% in the NC group.

CONCLUSION

Treatment of PDA in 5-14 y school children was quite adapted according to the recommendations. However, total control was reported in low percentages of patients reflecting universal discrepancy between evidence base medicine and real life.

Chronic bronchitis and pesticide exposure: a case–control study in Lebanon

OBJECTIVE

Pesticides are widely used toxics. The objective of the study is to evaluate the odds of exposure to pesticides in chronic bronchitis patients.

METHODS

Using the American Thoracic Society standardized questionnaire confirmed by medical diagnosis of chronic bronchitis, a case-control study was performed in Lebanon. Pesticide exposure was estimated and between groups comparison was made.

RESULTS

The study involved 262 controls and 110 chronic bronchitis outpatient subjects from 10 medical centers. Any exposure to pesticides was associated to chronic bronchitis (OR = 2.46 [1.53-3.94]; p < 10(-4)). Occupational use presented the highest association (15.92 [3.50-72.41]; p < 10(-4)), followed by regional exposure (3.70 [2.05-6.70]; p < 10(-4)). Results were confirmed by multivariate and subgroup analysis.

CONCLUSION

Pesticide exposure was associated with chronic bronchitis in Lebanese adults. Pesticides toxicological effects may explain chronic respiratory effects associations found with all exposure types.

Respiratory diseases and pesticide exposure: a case-control study in Lebanon

STUDY OBJECTIVE

To evaluate the odds of being exposed to pesticides in asthmatic adults.

DESIGN

A case-control study was performed in Lebanon.

SETTING

People were approached when consulting physicians as outpatients.

PATIENTS

Asthmatic patients and non-asthmatic controls in several Lebanese hospitals were interviewed.

MAIN RESULTS

The study included 407 subjects from 10 medical centres. Any exposure to pesticides was associated to asthma (OR = 2.11 (1.47 to 3.02); p<10(-4)). Occupational use presented the highest association (OR = 4.98 (1.07 to 23.28); p = 0.02), followed by regional exposure (OR 3.51 (2.11 to 5.85); p<10(-4)). Results were confirmed by multivariate analysis, particularly for regional exposure (OR(a) = 2.78; p = 0.02) and house exposure (OR(a) = 2.17; p = 0.001).

CONCLUSIONS

Results are comparable to those found in other studies; especially for occupational exposure. Pesticides toxicological effects may explain chronic respiratory symptoms and asthma associations found with all exposure types. Pesticide exposure was associated with asthma in Lebanese adults.

Asthma, allergic rhinitis and eczema in 13-14-year-old schoolchildren across Lebanon

INTRODUCTION

Childhood asthma is one of the most important diseases of childhood. There is no known prevalence of asthma and allergic diseases in Lebanon. This study was conducted with a primary objective of finding the prevalence of asthma, allergic rhinitis and eczema in Lebanese children.

MATERIAL AND METHODS

It is a descriptive cross-sectional study on children in Lebanese public and private schools. A sample of 22 schools participated in the study, where standardized ISAAC written core questionnaires were distributed. 13-14-year-old students filled in the questionnaires in class.

RESULTS

1613 individuals were analyzed. The prevalence of diagnosed asthma (5.6%) is the lowest in Lebanon compared to the eastern Mediterranean countries. Prevalence of ever wheezing (21.4%), last 12 months wheezing (19.9%), wheezing on effort (12.7%), night cough (22.8%), allergic rhinitis (32.7%) and eczema (11.5%) is on the medium prevalence trend noted all over the world, referring to ISAAC study. It also showed marked variations and differences across the governates in Lebanon, the lowest prevalence of diagnosed asthma (1.9%) but the highest prevalence of asthma symptoms like ever wheezing being in the Bekaa governate (26.8%).

CONCLUSION

Undiagnosed asthma, rhinitis and eczema have medium prevalence in Lebanon. Differences exist between Lebanese governates. Further studies are needed to understand the environmental, climate and socioeconomic causes of these discrepancies.

Spirometric changes following the use of pesticides

We compared the respiratory function of 19 pesticide factory workers and a control group of 43 other factory workers in Lebanon. The groups had no difference in smoking status. Baseline measurements of respiratory function showed significantly lower forced expiratory volume and flow rates (FEV1, FEF(25-75%), and FEV1/FVC ratio) among subjects working with pesticides, i.e. obstruction may be linked to chronic exposure to pesticides. After 4 hours of work, all respiratory variables were still significantly lower in pesticide-exposed subjects, but no acute changes in respiratory function were seen. Pesticide-exposed workers had 5.6 times higher risk of abnormal FEV1/FVC ratio and 16.5 higher risk for abnormal FEF(25-75%). Duration of occupation in the pesticide factory was significantly correlated with abnormal respiratory measures.