Statins, commonly coprescribed drugs, and concomitant risk factors: A protective, neutral, or harmful association with common cancer types development: A 10-year multicentric retrospective lebanese study

Elevated blood levels of low-density lipoprotein cholesterol are a major cardiovascular risk factor, and cholesterol-lowering drugs are among the most prescribed drugs worldwide. Cancer is the second leading cause of death after cardiovascular diseases. The relationship between cancer development and statins intake is controversial, and there are no clear studies in Lebanon and the Middle East concerning this topic. Hence, our study aimed to search for any possible association of statin intake as well as other medications (proton pump inhibitors [PPI], metformin, Aspirin, Angiotensin-Converting Enzyme inhibitors, and fenofibrate) with lung, colorectal cancer (CRC), and bladder cancer development in the Lebanese population. A retrospective study was performed on 709 subjects divided into 2 main groups: control (no cancer ± statin intake), and cases (either lung, or colorectal, or bladder cancer ± statin intake). Collected data included the age and gender of the patient, socioeconomic status, presence of cardiovascular disease and comorbidities, cancer risk factors, and the intake type, dose, and duration of statins. Bivariate, multivariate, and binary logistic analyses were enrolled. Out of 709 participants, 63.2% were males and 75% were cancer-positive (24.1%: lung cancer, 26.7%: CRC, 24.1%: bladder cancer). The overall intake of statins was not shown to significantly affect cancer development. However, a duration-response relationship was established between Simvastatin and lung cancer (odds ratio [OR]=1.208) as well as bladder cancer (OR=1.189). No significant association was found between each statin and CRC. Although PPIs intake was associated with a possibly harmful effect on lung cancer development (OR=3.42), it revealed a protective association with CRC development (OR=0.38). Other risk factors such as smoking and age were strongly associated (harmful) with lung and bladder cancer development. Physical inactivity and a family history of CRC were each associated with a harmful effect on CRC development. A harmful association with the development of lung and bladder cancer was found with the increasing duration of intake of Simvastatin. Other drugs such as PPIs and specific risk factors were also associated negatively or positively with the development of these 3 cancers. These findings should be validated by further investigations to guide clinicians on optimal treatment options for their patients.

The association between angiotensin receptor blockers and lung, bladder, and colon cancer development: A 10-year multicentric retrospective Lebanese study

Cardiovascular diseases (CVD) are the leading cause of death globally, followed by cancer. Angiotensin II contributes greatly to CVD pathogenesis, and Angiotensin II receptor blockers (ARBs) constitute a mainstay in hypertension and CVD management. However, the relationship between ARBs and cancer initiation is controversial, with no clear data in Lebanon. Therefore, our study aimed to determine the association between ARBs intake and lung, bladder, and colorectal cancers development in the Lebanese population. A retrospective study was conducted on 709 subjects divided into 2 main groups: Control (subjects without cancer; n = 177), and Cases (patients with cancer (n = 532): lung, bladder, or colorectal), taking ARBs (n = 236, (n = 121 in control and n = 115 in cases)) or not (n = 473). Collected information included the patients demographics, comorbidities, cancer's risk factors, and ARBs dose and duration intake. Bivariate, multivariate, and binary logistic analyses were enrolled. ARBs use was significantly protective (P value = 0.000) against overall cancer development (odds ratio [OR] = 0.127) and against each, lung (OR < 1), bladder (OR < 1), and colorectal cancers (OR < 1). A duration-response relationship was established. This protective effect and the time-dependent relationship remained unchanged after omitting the most relevant risk factors. In summary, a significant overall protective effect of ARBs against lung, bladder and colorectal cancers was found. This beneficial response was time-dependent. These results can guide patients on treatment options and clinicians for informed decision-making.

Sleep Quality and Nicotine Dependence Among Lebanese University Residents and Fellows: A Cross-Sectional Study

Background and objectives Sleep quality and nicotine addiction are important public health issues with significant negative impacts on individual well-being and the performance of healthcare professionals. This study aims to determine the prevalence and association of nicotine dependence and poor sleep quality among residents and fellows enrolled in the Lebanese University. Methods A cross-sectional study using the snowball-sampling technique was conducted in Lebanon between January and March 2023. Data were collected through an online survey that included information on socio-demographic characteristics, nicotine dependence, and sleep quality. A total of 350 residents and fellows were included in the study. Bivariate analysis and multivariable logistic regression were carried out to identify the factors associated with sleep quality. Adjusted odds ratio and 95% confidence intervals were reported. Results One quarter (25.1%) of the residents and fellows were smokers; among them, 44.3% smoked I Quit Ordinary Smoking (IQOS), 14.8% smoked cigarettes, 10.2% smoked waterpipe (WP), 12.5% smoked cigarettes and WP, and 18.2% smoked IQOS and WP. According to the Pittsburgh Sleep Quality Index (PSQI), 34.3% of participants had poor sleep quality. Smokers had 12.5 times higher odds of experiencing poor sleep quality compared to non-smokers (adjusted odds ratio ORadj = 12.58 with 95% confidence interval [CI] of 7.07-22.36; p-value <0.001). In addition, smoking a combination of two types of tobacco products (cigarettes with WP or IQOS with WP) posed the highest risk of poor sleep quality, with an adjusted odds ratio of 31.54 (95% CI of 9.15-45.74, p-value <0.001). Elevated Fagerström Test for Nicotine Dependence (FTND) and Lebanon Waterpipe Dependence Scale (LWDS-11) scores indicated an increased risk of poor sleep quality (adjusted odds ratio ORadj = 4.69 with 95% CI of 2.179-10.10; p-value <0.001; and adjusted odds ratio ORadj =1.27 with 95% CI of 1.04-1.55; p-value 0.019, respectively). Conclusion Our study found a significant association between nicotine dependence and poor sleep quality among medical residents and fellows, with smokers being more susceptible to sleep disturbances. The high prevalence of IQOS smoking among medical residents and fellows in Lebanon highlights the urgent need for comprehensive research investigating the effects of heated tobacco products. Furthermore, our study reveals a critical insight into the potential additive effects of nicotine, suggesting that the concurrent use of multiple tobacco products may further elevate the risk of poor sleep quality. Recognizing the implications of our findings, it is imperative to develop targeted interventions and educational programs that promote healthier sleep habits and facilitate smoking cessation among medical residents and fellows.

An Update on Acute Appendicitis in Lebanon: Insights From a Single-Center Retrospective Study

Background Acute appendicitis is the most common surgical emergency worldwide with scarce reports about its prevalence in the Middle East. To date, no epidemiological article has described the incidence of appendicitis in Lebanon. Our primary objective was to estimate the rate of appendicitis in a single center in Lebanon. Our secondary objectives included identifying differences between simple and complicated appendicitis regarding demographics, pre and postoperative characteristics, and symptoms and signs of appendicitis. Methodology A retrospective study was conducted at a single central university hospital in Lebanon. Patients with a clear diagnosis of acute appendicitis were included. Pregnant women, lactating women, patients with organ dysfunction, and patients younger than 18 years old or older than 80 years old were excluded. We reviewed and collected the data of patients who presented to the hospital between November 2018 and November 2019 and November 2020 and November 2021. Results A total of 95 patients were included in our study, with 35 women and 60 men. The mean body mass index of patients with simple appendicitis was 19.14 ± 9.66 kg/m² compared to 18.97 ± 10.37 kg/m² in patients with complicated appendicitis (p = 0.94). A total of 42.3% of patients who used antibiotics 24 hours after the operation had simple appendicitis, whereas 20.8% had complicated appendicitis (p = 0.004). Conclusions Antibiotic usage and the length of hospital stay were correlated with the severity of appendicitis, as reported in the literature. Further randomized studies with a larger number of patients and covering several hospitals in Lebanon are warranted.

The mediating role of anxiety and depression between problematic social media use and bulimia nervosa among Lebanese university students

Background

Bulimia nervosa (BN) is a disorder that is characterized by binge eating and inappropriate compensatory behavior to control weight. The aim of this study was to evaluate the mediating role of anxiety and depression between problematic social media use (PSMU) and BN among a sample of Lebanese university students.

Methods

This cross-sectional study was carried out between July and September 2021; a total of 363 university students was recruited through convenience sampling. The PROCESS SPSS Macro version 3.4, model four was used to test the indirect effect and calculate three pathways. Pathway A determined the regression coefficient for the effect of PSMU on mental health issues (depression/anxiety); Pathway B examined the association between mental health issues on BN, and Pathway C’ estimated the direct effect of PSMU on BN. Pathway AB was used to calculate the indirect effect of PSMU on BN via depression/anxiety.

Results

Results showed that depression and anxiety partially mediated the association between PSMU and BN. Higher levels of PSMU were associated with more depression and anxiety; higher depression and anxiety were associated with more BN. PSMU was directly and significantly associated with more BN. When entering anxiety (M1) then depression (M2) as consecutive mediators in a first model, the results showed that only depression mediated the association between PSMU and bulimia. When taking depression (M1) then anxiety (M2) as consecutive mediators in a second model, the results showed that the mediation PSMU → Depression → Anxiety → Bulimia was significant. Higher PSMU was significantly associated with more depression, which was significantly associated with more anxiety, which was significantly associated with more bulimia. Finally, higher PSMU was directly and significantly associated with more bulimia

Conclusion

The current paper highlights the relationship that social media use has on BN and other aspects of mental health such as anxiety and depression in Lebanon. Future studies should replicate the mediation analysis conducted in the current study while taking into account other eating disorders. Additional investigations of BN and its correlates must strive to improve the comprehension of these associations’ pathways through designs that allow to draw temporal frameworks, in order to efficiently treat this eating disorder and prevent its negative outcomes.

Bulimia nervosa, an eating disorder, is characterized by an impulsive consumption of food in a short period of time, followed by behaviors that compensate the eating such as vomiting or excessive exercise in order to avoid weight gain. Individuals with problematic social media use were found to have higher levels of bulimia symptoms. Symptoms of bulimia can also be associated with both depression and anxiety. The aim of the current study was to examine the mediating role of anxiety and depression between problematic social media use and bulimia nervosa. The results of our study found that problematic social media use was directly associated with more bulimia nervosa and also associated with higher depression and anxiety, both of which were associated with bulimia nervosa. Tackling associated disorders may help reduce symptoms of bulimia nervosa. Clinicians should carefully examine these associations while assessing and implementing treatment plans.

Rapid tranquillisation in a psychiatric emergency hospital in Lebanon: TREC-Lebanon - a pragmatic randomised controlled trial of intramuscular haloperidol and promethazine v. intramuscular haloperidol, promethazine and chlorpromazine

BACKGROUND

Agitated patients constitute 10% of all emergency psychiatric treatment. Management guidelines, the preferred treatment of clinicians differ in opinion and practice. In Lebanon, the use of the triple therapy haloperidol plus promethazine plus chlorpromazine (HPC) is frequently used but no studies involving this combination exists.

METHOD

A pragmatic randomised open trial (September 2018-July 2019) in the Lebanese Psychiatric Hospital of the Cross in Beirut Lebanon involving 100 people requiring urgent intramuscular sedation due to aggressive behaviour were given intramuscular chlorpromazine 100 mg plus haloperidol 5 mg plus promethazine 25 mg (HPC) or intramuscular haloperidol 5 mg plus promethazine 25 mg.

RESULTS

Primary outcome data were available for 94 (94%) people. People allocated to the haloperidol plus promethazine (HP) group showed no clear difference at 20 min compared with patients allocated to the HPC group [relative risk (RR) 0.84, 95% confidence interval (CI) 0.47-1.50].

CONCLUSIONS

Neither intervention consistently impacted the outcome of 'calm', or 'asleep' and had no discernible effect on the use of restraints, use of additional drugs or recurrence. If clinicians are faced with uncertainty on which of the two intervention combinations to use, the simpler HP is much more widely tested and the addition of chlorpromazine adds no clear benefit with a risk of additional adverse effects.

Quality of Life in Adult Patients With Epilepsy in Lebanon: A Cross-Sectional Study

BACKGROUND

Epilepsy is a chronic and heterogeneous neurological disorder that impairs the quality of life (QOL) of sufferers and affects their mental health in many aspects. Few studies have been conducted in the Middle East, especially in Lebanon, on the QOL of patients with epilepsy. The aim of our study is to assess the burden of epilepsy on the life of adult patients in Lebanon and measure the impact of sociodemographic and clinical factors on the QOL.

MATERIALS AND METHODS

A total of 47 patients from several neurology clinics were included in our study and asked to fill out a questionnaire including the sociodemographic variables and epilepsy-related factors. We used the Quality of Life in Epilepsy Scale-31 (QOLIE-31), which is a 31-question form covering seven attributes of the QOL; overall QOL, emotional wellbeing, social functioning, cognition, energy, seizure worry and medication effects, to assess the QOL of adult patients with epilepsy. Analysis was conducted using SPSS program version 23.

RESULTS

The mean age of our sample was 37.54 years, 53.2% of which were males. The majority were unemployed, educated, and belonging to the medium socioeconomic level. The highest subscale score was for the social functioning subscale with a mean of 74.49±25.89 and the lowest subscale score was for seizure worry with a mean of 55.81±27.14. Employment status, nationality, and socioeconomic level were shown to be associated with the QOL scores. There were no correlations between the clinical factors and the QOL scores.

CONCLUSION

 Sociodemographic factors, namely Lebanese nationality, employment status, and socioeconomic level, were associated with better QOL, reflected by the significant associations between the following parameters and the QOL scores (p-value<0.05), highlighting the positive influence of social support on the outcome of the disease. However, epilepsy-related clinical features did not show any correlation with the QOL and its subscales.

Trends & predictors of non-AIDS comorbidities among people living with HIV and receiving antiretroviral therapy in Lebanon

Combined antiretroviral therapy (cART) increased the life expectancy of people living with Human Immunodeficiency Virus (HIV) (PLHIV) and remarkably reduced the morbidity and mortality associated with HIV infection. Consequently, PLHIV are experiencing non-acquired immunodeficiency syndrome (AIDS) associated comorbid conditions including diabetes, hyperlipidemia, hypertension, and cardiovascular disease. The aim of this study is to determine the frequency of non-AIDS associated comorbid conditions among a cohort of PLHIV on cART in Lebanon.Data were collected between November 2018 and December 2019 from 105 voluntary participants. A standardized questionnaire was used to collect demographic and behavioral data including lifestyle, smoking, physical activity, substance use and abuse in addition to co-infections and family history of non-communicable diseases. Moreover, data on occurrence and treatment of cardiovascular disease, hypertension, diabetes, lipid and metabolic disorders as well as mental health were collected. Blood samples were used to assess the levels of fasting blood sugar (FBS), glycosylated hemoglobin (HbA1C), triglycerides (TG), low-density lipoprotein (LDL), high-density lipoprotein, total cholesterol, and serum creatinine.Hypertension (29.5%) and hyperlipidemia (29.5%) followed by diabetes (23.7%) and cardiovascular disease (9.7%) were mainly reported among study participants. Higher rate of comorbid conditions was observed among participants >40 years of age than those ≤40 years with both hypertension and hyperlipidemia most commonly reported. Older age (odds ratio [OR] 7.6; 95% CI: 1.83-31.98; P = .005) is associated with higher odds of having hyperlipidemia. Moreover, participants on cART for ≥10 years are 5 times more likely to have hyperlipidemia (OR 5; 95% CI: 1.08-22.73; P = .039). Our results also showed that study participants did not experience anxiety, depression or somatic symptoms and that there was no association between these mental disorders and older age or comorbidities.Our results provide important information on HIV trends and associated comorbidities in Lebanon and can be used to improve the management of non-communicable diseases among PLHIV.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

QTc prolongation during levofloxacin and triazole combination chemoprophylaxis: Prevalence and predisposing risk factors in a cohort of hematopoietic cell transplantation recipients

BACKGROUND

QTc interval prolongation has been reported when combining fluoroquinolones and triazoles for chemoprophylaxis in cancer patients. Herein, we aimed to identify the prevalence and contributing factors to QTc prolongation in hematopoietic cell transplantation (HCT) recipients who received these agents during the neutropenic phase.

METHODS

This is a retrospective medical chart review conducted at a university hospital in Lebanon from 2017 to 2020. It included all adult HCT inpatients on antimicrobial prophylaxis with fluoroquinolones and triazoles and whose baseline ECG monitoring done prior to chemoprophylaxis administration, then on day-3 and day-6 of therapy, were available.

RESULTS

Overall, 68 HCT recipients met our inclusion criteria, of which 22% developed QTc prolongation. Based on bivariate analysis, female gender contributed to QTc prolongation (P = 0.001). There was a trend to QTc prolongation in patients with predisposing thyroid disease (P = 0.12), grade 2 vomiting and diarrhea (P = 0.16, P = 0.46, respectively), baseline hypokalemia (P = 0.18) and hypocalcemia (P = 0.3), hypomagnesemia on day-3 (P = 0.21) and day-6 hyponatremia (P = 0.36). Patients receiving two or more drugs with a known or probable risk of QTc prolongation (other than the fluoroquinolone/ triazole combination) were more prone to experience a prolonged QTc interval (P = 0.09). None of the patients that had QTc prolongation died or developed serious arrhythmias.

CONCLUSION

The prevalence of QTc prolongation was 22% among HCT recipients on fluoroquinolone and triazole prophylaxis, yet we did not identify any independent risk factors for this issue. None of the patients that had QTc interval prolongation died or developed serious arrhythmias.

Epidemiology and Incidence of Retinoblastoma in the Middle East: A Nationwide Study in Lebanon

Background: Retinoblastoma, although a rare pediatric cancer, can lead to disastrous outcomes if not managed early. This mishap often happens in developing countries. Conversely, early diagnosis and treatment of retinoblastoma in developed countries were associated with a surge in RB1 gene carriers.

Aim: The authors aimed to evaluate the incidence of retinoblastoma in the Lebanese population aged between 0 and 19 years according to age, sex, and other variables and compare the age-standardized incidence rates with regional and worldwide countries.

Methods: Data were retrieved from the National Cancer Registry (NCR) of the Ministry of Public Health (MOPH). Subsequently, incidence rates, age-standardized rates, and fictional incidence rates excluding the emigrant population were calculated. Retinoblastoma trends were found using the Joinpoint regression program software.

Results: From the 38 cases of retinoblastoma recorded in the nine years cohort, 29 cases occurred in the 0-4 age group, and age-standardized rates were 2.8 and 3.6 per million person-years for the 0-19 and 0-14 age groups, respectively. When the refugee population was excluded, the ASR 0-19 almost doubled from 2.8 per million person-years to 5.16 per million person-years. Joinpoint regression revealed that retinoblastoma trends were divided into two segments showing a decrease from 2005 until 2011 and a rising trend in 2011-2015. When compared to other countries in the region, Lebanon had low-intermediate 0-19 ASRs.

Conclusion: Retinoblastoma incidence in Lebanon is in the lower margin of the worldwide average and could be underestimated due to the underdiagnosis in the refugee population. Efforts are being deployed to overcome the financial barriers in the treatment of retinoblastoma by coordinating with neighboring Arab countries.

Distribution of Primary Brain Tumor Subtypes in Lebanon: A Multicenter Eleven-Year Study of 695 Patients

Background

Brain tumors are associated with relatively high mortality and morbidity in comparison with their low incidence. Little is known about primary brain tumors in Lebanon, as well as in the Arab world. This study aims to analyze the epidemiology of brain tumors across the Lebanese population.

Methods

Data from pathology reports of patients diagnosed with malignant and non-malignant primary brain tumors were collected retrospectively in an eleven-year period (2007-2017) from four medical centers in Lebanon. A total of 695 primary brain tumor cases (61% malignant and 39% non-malignant) were retrieved from different regions across the country.

Results

Meningiomas were the most common histology in this sample (29.6%), followed by glioblastomas (25.5%) and oligodendrogliomas (5.9%). Pituitary tumors were only 3.5% of brain tumors. Besides, the most common anatomical locations in malignant and non-malignant tumors were cerebral meninges (29.6%), the "other brain" category (21.3%), and the frontal lobe (11.2%). In children and adolescents, embryonal tumors (21%) were the most common histologies, while glioblastomas and meningiomas accounted for 14.8% and 13.6%, respectively.

Conclusion

Lebanon presented a low rate of pituitary tumors and an unusually high percentage of malignant tumors, as well as pediatric glioblastomas and meningiomas. This should raise major concerns for policymakers to detect the possible underlying causes.

A 20-year Clinical and Genetic Neuromuscular Cohort Analysis in Lebanon: An International Effort

BACKGROUND

Clinical and molecular data on the occurrence and frequency of inherited neuromuscular disorders (NMD) in the Lebanese population is scarce.

OBJECTIVE

This study aims to provide a retrospective overview of hereditary NMDs based on our clinical consultations in Lebanon.

METHODS

Clinical and molecular data of patients referred to a multi-disciplinary consultation for neuromuscular disorders over a 20-year period (1999-2019) was reviewed.

RESULTS

A total of 506 patients were diagnosed with 62 different disorders encompassing 10 classes of NMDs. 103 variants in 49 genes were identified. In this cohort, 81.4%of patients were diagnosed with motor neuron diseases and muscular dystrophies, with almost half of these described with spinal muscular atrophy (SMA) (40.3%of patients). We estimate a high SMA incidence of 1 in 7,500 births in Lebanon. Duchenne and Becker muscular dystrophy were the second most frequently diagnosed NMDs (17%of patients). The latter disorders were associated with the highest number of variants (39) identified in this study. A highly heterogeneous presentation of Limb Girdle Muscular Dystrophy and Charcot-Marie-Tooth disease was notably identified. The least common disorders (5.5%of patients) involved congenital, metabolic, and mitochondrial myopathies, congenital myasthenic syndromes, and myotonic dystrophies. A review of the literature for selected NMDs in Lebanon is provided.

CONCLUSIONS

Our study indicates a high prevalence and underreporting of heterogeneous forms of NMDs in Lebanon- a major challenge with many novel NMD treatments in the pipeline. This report calls for a regional NMD patient registry.

Factors Associated with Mental Health Outcomes: Results from a Tertiary Referral Hospital in Lebanon during the COVID-19 Pandemic

Coronavirus Disease (COVID-19) has caused global mental health impacts, and healthcare workers (HCWs) face an increased risk of exposure to the disease when compared to the general population. This study aimed to assess factors associated with mental health among Lebanese HCWs six months after the start of the COVID-19 pandemic. A cross-sectional study was conducted among HCWs at a tertiary hospital, in Lebanon between June and July 2020. The survey included data on demographics, exposure to COVID-19, preparedness to COVID-19 outbreak, risk perceptions of COVID-19, and mental health dimensions. Chi-squared and Fisher’s exact tests were used to understand the association among these variables. One hundred and ninety-three of 1,600 Lebanese HCWs participated. More than 80% reported high preparedness levels towards the COVID-19 outbreak, 69% believed that their job was putting them at risk, and 70% altruistically accepted these risks. Anxiety and depression symptomatology were present in 24% and 23% of HCWs; who were more likely to feel more stress at work (83% vs 60%; p = 0.004; 82% vs 61%; p = 0.01, respectively), feel afraid of falling ill (72% vs 55%; p = 0.03; 77% vs 54%; p = 0.01, respectively), fear death (21% vs 7%; p = 0.01; 25% vs 6%; p ≤ 0.001, respectively), and believed that people avoided their families (39% vs 21%; p = 0.01; 35% vs 65%; p = 0.02, respectively). HCWs who reported signs of depression were less likely to altruistically accept the risks of caring for COVID-19 patients, compared to those who did not (57% vs 74%; p = 0.03). This study aimed to detect factors associated with mental health among Lebanese HCWs during the COVID-19 pandemic. Findings suggested that altruistic acceptance of COVID-19 risks is higher among HCWs with positive exposure history to COVID-19 and those with less depressive symptomatology.

Lebanese Healthcare System: How Will the Aftermath Look?

The recent Lebanese port explosion came as a continuation of a series of socioeconomic disasters the country has been facing during the past year. In addition, the massive impact of the coronavirus disease-19 (COVID-19) pandemic further hastened the collapse of the Lebanese healthcare system. In light of all those events, the Lebanese healthcare sector has faced major blows that will be difficult to recuperate from. In the aftermath of the Beirut port explosion, Lebanon received immense financial and medical support from the international community in a timely fashion, which secured first level care to victims of the explosion. Nevertheless, this forced Lebanon, which was considered a prominent tertiary medical hub in the Middle East, to slowly regress into an exclusive primary care provider. As such, it is crucial for local and regional stakeholders to build strong collaborations, and shape a unified vision of Lebanon's future healthcare system.

A 12-Year Comparative Analysis of Hodgkin and Non-Hodgkin Lymphomas in Lebanon: Trend Characteristics and 10-Year Projections

Background  Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) are two common malignancies worldwide and in Lebanon. Analysis of their trends plays a crucial role to better understand their origins and risk factors. This study will probe incidences of both types of lymphomas from 2005 to 2016, aiming to compare between the two malignancies according to age and sex and plot projections until 2026. Methods HL and NHL cases from 2005 to 2016 were collected from the National Cancer Registry of Lebanon. Data was stratified according to age and sex. Age-specific and age-standardized incidence rates were analysed using joinpoint regression; 10-year projections were predicted based on logarithmic models. Results Between 2005 and 2016, NHL was significantly more common than HL. NHL was higher in both genders. HL showed a bimodal age distribution while NHL peaked in elderly patients. NHL incidence rates in males increased significantly from 2005 to 2014 while HL incidence rates showed an insignificant rise. Over the next 10 years, NHL and HL cases are expected to increase in Lebanon. Conclusion HL and NHL are on the rise in Lebanon. Extensive research into the main factors contributing to these lymphomas is crucial in the fight against them. More efforts must be done by the government and health organizations to better control the disease.

First Case of an Infant with COVID-19 in the Middle East

The novel coronavirus (COVID-19) has been declared a worldwide pandemic. It was initially thought to spare children and adolescents as significantly smaller number of cases have been reported in the pediatric population in comparison to adults. Here, we report the case of a 16-month-old female infant from Lebanon who presented with fever and severe diarrhea and tested positive for COVID-19. Her symptoms started six days prior to presentation with no cough, rhinorrhea, or other respiratory manifestations reported. Chest radiography showed lobar consolidation and bronchial infiltrates. Blood culture was positive for Streptococcus pneumoniae. Stool and urine cultures were negative. She was treated with ceftriaxone and metronidazole. Her RT-PCR test was negative after five days of treatment, suggesting that children can clear the virus faster than adults. The patient likely contracted the virus from her parents, who because of the fear of social stigma hide recent history of respiratory illness. These findings serve as a practical reference for the clinical diagnosis and medical treatment of children with COVID-19.

Evaluating the feasibility, acceptability and pre testing the impact of a self-management and tele monitoring program for chronic obstructive pulmonary disease patients in Lebanon: Protocol for a feasibility study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) has a significant impact on quality of life and is costly to the health care system. It has been demonstrated that a self-management program improves quality of life, but programs are not universally available and telehealth interventions can provide home-based support, but have mixed results.

AIM

The aims of this study are to (1) assess the feasibility and acceptability of a 6 weeks' educational program related to self-management with remote monitoring for Lebanese COPD patients; (2) pre-test its impact on quality of life, emergency visits, and rate of rehospitalization, and (3) to make recommendations for a future randomized trial.

METHODS

Validated questionnaires will be adapted to meet the context of our study in terms of acceptability, adoption, adequacy, fidelity, cost, and coverage. The impact of this program on quality of life will be measured with the COPD assessment test (CAT) and the COPD clinical questionnaire (CCQ), and the Hospital Anxiety and Depression (HAD) scale will be used to measure anxiety. All measures will be delivered pre- and post-intervention. To evaluate the impact of our program on the rate of hospitalization and emergency visits, the number of hospitalizations and emergency room visits during the year preceding the intervention will be collected from the hospital register of each participant.

DISCUSSION

This study is the first to evaluate the application of telehealth to optimize COPD management in Lebanon. The results of this study will provide evidence regarding the efficacy and feasibility of this approach for Lebanese patients with moderate to severe COPD.

Interfacility patient transfers in Lebanon-A culture-changing initiative to improve patient safety and outcomes

Organizing interfacility transfers is an essential component of regionalized care to improve patient outcomes. This study examines transfer characteristics after establishing a transfer center in a tertiary care center in Beirut Lebanon, and identifies predictors of success in patient transfers.This retrospective observational chart review examined all transfer center requests to and from the tertiary care center over a 4-year period (2013-2017). Descriptive analysis was done, followed by a bivariate analysis comparing transfers based on final decision (accepted yes/no) and by a multivariate logistic regression to identify predictors of successful transfers.A total of 4100 transfer requests were analyzed. Incoming transfer requests were more common than outgoing requests (56.5% vs 43.4%) and were mainly for adult patients (71.0% incoming and 78.7% outgoing). Reasons of transfers were mostly medical (99.4%) for incoming transfers and financial (73.1%) and medical (17.9%) for outgoing transfers. Requested level of care was most commonly intensive care unit for incoming transfers (61.6%) and regular floor for outgoing transfers (48.6%). Outgoing transfers were more successful than incoming transfers (59.9% vs 39.6%). Predictors of success in patient transfers within the healthcare system were identified: These included specific types of financial coverage, diagnoses, levels of care, and medical services for incoming transfers in addition to age groups and receiving hospital location for outgoing transfers.Transfer centers can be implemented successfully in any healthcare system to improve patient care and safety. Identifying facilitators and barriers to successful transfers can help healthcare administrators and policymakers address gaps in the system and improve access to care.

Beliefs, practices and knowledge of community pharmacists regarding complementary and alternative medicine: national cross-sectional study in Lebanon

INTRODUCTION

Pharmacists are uniquely positioned to provide patients with evidence-based information in order to ensure effective and safe use of Complementary and alternative medicine (CAM) products.

OBJECTIVE

Assess beliefs, practices and knowledge related to CAM products among community pharmacists in Lebanon.

DESIGN, METHODS AND SETTING

Using stratified random sampling, a nationally representative survey was conducted among community pharmacists in Lebanon. Through face-to-face interviews, pharmacists completed a multicomponent questionnaire consisting of four sections: (1) sociodemographic characteristics; (2) beliefs related to regulation of CAM products, role of media in promoting their safe use, availability of resources and continuing education; (3) practices including selling CAM products, providing advice for patients and reporting adverse effects and (4) knowledge about specific CAM products, their uses, side effects and interactions.

RESULTS

A total of 341 pharmacists agreed to participate (response rate: 86%). Only pharmacists with complete data were included in this study (n=310). Pharmacists agreed that CAM products are effective (63.8%) and that they should be exclusively sold in pharmacies (80.3%), but disagreed that commercially marketed CAM products are well regulated (63.5%) and that media plays a positive role in educating users about these products (55.8%). As for practices, 64.5% of pharmacists were always or often advising patients on safe use; however, 74.2% of participants rarely or never reported adverse effects. Regarding knowledge, although the majority of pharmacists were aware of the uses of CAM products, fewer knew about their side effects and their interactions with drugs. After adjustment for covariates, receiving education/training on CAM products during university was the sole predictor of higher knowledge score (ß=0.68, 95% CI 0.29 to 1.07).

CONCLUSIONS

This study revealed positive beliefs of pharmacists in Lebanon towards CAM products and indicated important gaps in their practice and knowledge. Deliberate efforts to enhance the education of pharmacists are warranted to ensure the safe integration and use of CAM products in Lebanon.

Cognitive Reserve Factors in a Developing Country: Education and Occupational Attainment Lower the Risk of Dementia in a Sample of Lebanese Older Adults

Background: Dementia secondary to neurodegenerative diseases is prevalent among older adults and leads to social, psychological and economic burden on patients, caregivers and the community as a whole. Cognitive reserve factors such as education, and mental stimulation among others were hypothesized to contribute to the resilience against age-related cognitive impairment. Educational attainment, occupation complexity, physical activity, and leisure activity are explored in the context of protecting the older adults' cognitive function. We investigated the cognitive reserve effect on dementia, cognitive decline and impairment, and global cognitive function.

Methods: This study is a secondary analysis of data from a cross-sectional, community-based cohort study that aimed at investigating factors associated with dementia and their prevalence. The sample was of 508 community based older adults in Lebanon, aged 65 years and above in addition to 502 informants designated by these older adults. Older adults and informants answered structured questionnaires administered by interviewers, as well as a physical assessment and a neurological examination. Older adults were diagnosed for dementia. Global cognitive function, depression, and cognitive decline were assessed.

Results: Older adults with dementia had lower levels of education, and attained lower occupational complexity. Factors such as high education, complex occupation attainment, and leisure activity, significantly predicted better global cognitive function. An older adult who attained high education levels or high complexity level occupation was 7.1 or 4.6 times more likely to have better global cognitive function than another who attained lower education or complexity level occupation respectively.

Conclusion: These results suggest that cognitive reserve factors ought to be taken into consideration clinically during the course of dementia diagnosis and when initiating community-based preventive strategies.

Post-traumatic stress disorder in adult victims of cluster munitions in Lebanon: a 10-year longitudinal study

OBJECTIVE

This study aims to explore the short-term and long-term prevalence and effects of post-traumatic stress disorder (PTSD) among victims of cluster munitions.

DESIGN AND SETTING

A prospective 10-year longitudinal study that took place in Lebanon.

PARTICIPANTS

Two-hundred-and-forty-four Lebanese civilian victims of submunition blasts, who were injured in 2006 and were over 18 years old, were interviewed. Included were participants who had been diagnosed with PTSD according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) and the PTSD Checklist - Civilian Version in 2006. Interviewees were present for the 10-year follow-up.

MAIN OUTCOME MEASURES

PTSD prevalence rates of participants in 2006 and 2016 were compared. Analysis of the demographical data pertaining to the association of long-term PTSD with other variables was performed. p Values <0.05 were considered statistically significant for all analyses (95% CI).

RESULTS

All the 244 civilians injured by cluster munitions in 2006 responded, and were present for long-term follow-up in 2016. The prevalence of PTSD decreased significantly from 98% to 43% after 10 years (p<0.001). A lower long-term prevalence was significantly associated with male sex (p<0.001), family support (p<0.001) and religion (p<0.001). Hospitalisation (p=0.005) and severe functional impairment (p<0.001) post-trauma were significantly associated with increased prevalence of long-term PTSD. Symptoms of negative cognition and mood were more common in the long run. In addition, job instability was the most frequent socioeconomic repercussion among the participants (88%).

CONCLUSIONS

Psychological symptoms, especially PTSD, remain high in war-affected populations many years after the war; this is particularly evident for Lebanese civilians who were victimised by cluster munitions. Screening programmes and psychological interventions need to be implemented in vulnerable populations exposed to war traumas. Officials and public health advocates should consider the socioeconomic implications, and help raise awareness against the harm induced by cluster munitions and similar weaponry.

A retrospective analysis of 254 acute stroke cases admitted to two university hospitals in Beirut: classification and associated factors

Lebanon is a developing country where the prevalence of stroke subtypes and their correlation with risk factors have not been studied, even though stroke management is an ongoing major national healthcare challenge. In a retrospective study conducted in two university hospitals, data were collected on all stroke cases admitted in 2012 and 2013. Ischemic strokes were then classified according to a modified TOAST classification. A total of 254 inpatients (mean age 68.41 years ±13.34, 55.1% males) was included in the study; of these, 15% had had a hemorrhagic stroke and was therefore excluded. Conversely to findings from studies in other Arab and Asian countries, where small vessel disease is the most frequent subtype, our study showed a predominance of large artery atherosclerosis (53.5%) which, in comparison with other subtypes, was found to be associated with dyslipidemia (OR= 3.82, 95% CI= [1.76-8.28]; p=0.001). Cardioembolic stroke and small vessel disease were found to be positively associated with aging and living in Beirut, respectively. Larger studies are needed to explain these findings.

Epidemiology and clinical characteristics of traumatic brain injury in Lebanon: A systematic review

BACKGROUND

Traumatic brain injury (TBI) is a debilitating medical and emerging public health problem that is affecting people worldwide due to a multitude of factors including both domestic and war-related acts. The objective of this paper is to systematically review the status of TBI in Lebanon - a Middle Eastern country with a weak health system that was chartered by several wars and intermittent outbursts of violence - in order to identify the present gaps in knowledge, direct future research initiatives and to assist policy makers in planning progressive and rehabilitative policies.

METHODS

OVID/Medline, PubMed, Scopus databases and Google Scholar were lastly searched on April 15, 2016 to identify all published research studies on TBI in Lebanon. Studies published in English, Arabic or French that assessed Lebanese patients afflicted by TBI in Lebanon were warranting inclusion in this review. Case reports, reviews, biographies and abstracts were excluded. Throughout the whole review process, reviewers worked independently and in duplicate during study selection, data abstraction and methodological assessment using the Downs and Black Checklist.

RESULTS

In total, 11 studies were recognized eligible as they assessed Lebanese patients afflicted by TBI on Lebanese soils. Considerable methodological variation was found among the identified studies. All studies, except for two that evaluated domestic causes such as falls, reported TBI due to war-related injuries. Age distribution of TBI victims revealed two peaks, young adults between 18 and 40 years, and older adults aged 60 years and above, where males constituted the majority. Only three studies reported rates of mild TBI. Mortality, rehabilitation and systemic injury rates were rarely reported and so were the complications involved; infections were an exception.

CONCLUSION

Apparently, status of TBI in Lebanon suffers from several gaps which need to be bridged through implementing more basic, epidemiological, clinical and translational research in this field in the future.

Community involvement in out of hospital cardiac arrest: A cross-sectional study assessing cardiopulmonary resuscitation awareness and barriers among the Lebanese youth

Out of hospital cardiac arrest (OHCA) is a leading cause of death worldwide. Developing countries including Lebanon report low survival rates and poor neurologic outcomes in affected victims. Community involvement through early recognition and bystander cardiopulmonary resuscitation (CPR) can improve OHCA survival.This study assesses knowledge and attitude of university students in Lebanon and identifies potential barriers and facilitators to learning and performing CPR.A cross-sectional survey was administered to university students. The questionnaire included questions regarding the following data elements: demographics, knowledge, and awareness about sudden cardiac arrest, CPR, automated external defibrillator (AED) use, prior CPR and AED training, ability to perform CPR or use AED, barriers to performing/learning CPR/AED, and preferred location for attending CPR/AED courses. Descriptive analysis followed by multivariate analysis was carried out to identify predictors and barriers to learning and performing CPR.A total of 948 students completed the survey. Participants' mean age was 20.1 (±2.1) years with 53.1% women. Less than half of participants (42.9%) were able to identify all the presenting signs of cardiac arrest. Only 33.7% of participants felt able to perform CPR when witnessing a cardiac arrest. Fewer participants (20.3%) reported receiving previous CPR training. Several perceived barriers to learning and performing CPR were also reported. Significant predictors of willingness to perform CPR when faced with a cardiac arrest were: earning higher income, previous CPR training and feeling confident in one's ability to apply an AED, or perform CPR. Lacking enough expertise in performing CPR was a significant barrier to willingness to perform CPR.University students in Lebanon are familiar with the symptoms of cardiac arrest, however, they are not well trained in CPR and lack confidence to perform it. The attitude towards the importance of bystander CPR and the need to learn CPR is very positive. Interventions should focus on public awareness campaigns regarding the importance of initiating bystander CPR while activating emergency medical services (EMS) and on making CPR training more available.

Complementary and alternative medicine use and its association with quality of life among Lebanese breast cancer patients: a cross-sectional study

BACKGROUND

Breast cancer patients are increasingly seeking Complementary and Alternative Medicine (CAM) therapies with the hope of alleviating the burden of the disease and improving their quality of life (QOL). The objective of this study was to assess the prevalence, types, socio-demographic and disease-related correlates as well as characteristics of CAM use (including disclosure to treating physicians) among breast cancer patients in Beirut, Lebanon. A secondary objective was to evaluate the association between CAM use and QOL.

METHODS

A cross-sectional survey was conducted on breast cancer patients recruited from two major referral centers in Beirut: a philanthropic hospital and a private academic medical center. In face-to-face interviews, participants completed a questionnaire of three sections: socio-demographic and lifestyle characteristics, breast cancer condition, and CAM use. Three to four weeks following these interviews, the secondary QOL assessment was carried out via telephone using the Arabic version of the Functional Assessment of Cancer Therapy-Breast questionnaire. The main outcome in this study, CAM use, was defined as using CAM at least once after breast cancer diagnosis.

RESULTS

A total of 180 breast cancer patients completed the survey (response rate: 94.6 %). Prevalence of CAM use was 40 %. Using multivariate logistic regression, CAM use was negatively associated with age (OR: 0.96, CI: 0.92-0.99), treatment at the philanthropic hospital (OR: 0.13, CI: 0.05-0.35) and was positively associated with an advanced stage of the disease (OR: 4.20, CI: 1.65-10.69). Among study participants recruited from both sites, the most commonly used CAM was 'special food' followed by 'herbal teas', 'diet supplements' and 'Spiritual healing'. Only 4 % of CAM users cited health professionals as influencing their choice of CAM and only one in four patients disclosed CAM use to their treating physician. There was no significant association between CAM use and QOL.

CONCLUSIONS

The findings of this study revealed a prevalent CAM use among Lebanese breast cancer patients. Furthermore, physicians' role in orienting CAM use was found to be marginal as patients relied mainly on family and media for their choice of CAM and were less likely to disclose CAM use to their treating physicians.

Validation of the Arabic Version of the Memorial Symptom Assessment Scale Among Lebanese Cancer Patients

CONTEXT

To our knowledge, there have been no previous attempts to translate the Memorial Symptom Assessment Scale (MSAS) into the Arabic language and validate it among the Arab cancer population.

OBJECTIVES

The purpose of this study was to validate the MSAS in Arabic (MSAS-Leb) among 190 Lebanese oncology outpatients.

METHODS

The questionnaires were the MSAS-Leb and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30). Data were collected between 2009 and 2010 at a major teaching hospital in Lebanon. The psychometric indices used were reliability, convergent validity, principle component analysis, and confirmatory factor analysis (CFA).

RESULTS

The Cronbach's alpha coefficients for the MSAS and its subscales ranged from 0.71 to 0.83. On convergent validity testing, the psychological and global distress index subscales were moderately correlated (r > -0.50; P < 0.01) with the emotional functioning subscale of the EORTC QLQ-C30. Correlation coefficients between the MSAS items and selected subscales from the EORTC QLQ-C30 met the standards of convergent validity (r = -0.55 to 0.81; P < 0.01) except for the nausea/vomiting subscale. On principal component analysis (N = 95), four meaningful clusters were recovered. The clusters represented the psychological and physical components. CFA (N = 95) showed an acceptable model and a good fit (goodness-of-fit index = 0.59, adjusted goodness-of-fit index = 0.51, root mean square residual = 0.05, root mean square error of approximation = 0.2) with our data set.

CONCLUSION

The MSAS-Leb has acceptable psychometric properties of reliability and validity. We recommend its use in clinical practice and outpatient settings among health care professionals to assess and follow-up on symptom burden among patients diagnosed with cancer.

Diet, physical activity and socio-economic disparities of obesity in Lebanese adults: findings from a national study

BACKGROUND

The prevalence of obesity within countries varies by gender, age, lifestyle and socioeconomic factors. Identification of behavioural factors that are associated with obesity within the country's context is critical for the development of effective public health programs which aim to prevent and manage obesity. The objective of this study was to assess age and gender differentials in the prevalence of obesity in Lebanon and examine correlates of obesity with a focus on socioeconomic disparities.

METHODS

Following the WHO STEPwise guidelines, a national survey was conducted in Lebanon in 2008-2009. Households were selected randomly from all Governorates based on stratified cluster sampling method. One adult aged 20 years and over was randomly selected from each household for the interview. Anthropometric measurements and 24 hour recall dietary intake were obtained. The final sample included 1244 men and 1453 women. Descriptive statistics were computed for BMI, waist circumference, and percent body fat. Multivariate logistic regression analysis was carried out to assess the relationship between energy intake and obesity adjusted for relevant co-variables.

RESULTS

The prevalence of obesity among Lebanese adults was 26.1%. Gender differences in obesity estimates were observed across age groups and the three obesity classes, with men showing higher prevalence rates at the younger age groups (20-49 years), and women showing higher prevalence rates in older age groups (50 years and above). Obesity showed significant associations with socio-economic status in women; it decreased with higher educational attainment (OR = 0.54, 95% CI: 0.32, 0.91), greater household assets (OR = 0.26; 95% CI: 0.10, 0.72) and lower crowding index (OR = 0.62; 95% CI: 0.39, 0.98), net of the effect of other co-variates. There was a significant positive association between obesity and energy intake in both genders, and a negative association between obesity and physical activity, significantly among women.

CONCLUSION

Lifestyle and socioeconomic determinants of obesity are identified in this Lebanese population. Policy makers and service providers need to tailor public health strategies to tackle obesity accordingly.

HIV prevalence and demographic determinants of unprotected anal sex and HIV testing among men who have sex with men in Beirut, Lebanon

The limited epidemiological data in Lebanon suggest that HIV incident cases are predominantly among men who have sex with men (MSM). We assessed the prevalence of HIV and demographic correlates of condom use and HIV testing among MSM in Beirut. Respondent-driven sampling was used to recruit 213 participants for completion of a behavioral survey and an optional free rapid HIV test. Multivariate regression analysis was used to examine demographic correlates of unprotected anal sex and any history of HIV testing. Nearly half (47 %) were under age 25 years and 67 % self-identified as gay. Nearly two-thirds (64 %) reported any unprotected anal intercourse (UAI) with men in the prior 3 months, including 23 % who had unprotected anal intercourse with men whose HIV status was positive or unknown (UAIPU) to the participant. Three men (1.5 % of 198 participants tested) were HIV-positive; 62 % had any history of HIV testing prior to the study and testing was less common among those engaging in UAIPU compared to others (33 % vs. 71 %). In regression analysis, men in a relationship had higher odds of having UAI but lower odds of UAIPU and any university education was associated with having UAI; those with any prior history of HIV testing were more likely to be in a relationship and have any university education. HIV prevention efforts for MSM need to account for the influence of relationship dynamics and promotion of testing needs to target high-risk MSM.

A national study on nurses' retention in healthcare facilities in underserved areas in Lebanon

BACKGROUND

Nursing shortages and maldistribution are priority issues for healthcare systems around the globe. Such imbalances are often aggravated in underserved areas, especially in developing countries. Despite the centrality of this issue, there is a dearth of studies that examine the retention of nurses in underserved areas in the Middle East Region. This study investigates the characteristic and the factors associated with the retention of nurses working in rural areas in Lebanon.

METHODS

This study uses a non-experimental cross-sectional design to survey nurses working in underserved areas of Lebanon. Underserved areas in Lebanon were identified using WHO definition. A total of 103 health facilities (hospitals and primary healthcare centers) located in these areas were identified and all nurses working at these facilities received a copy of the survey questionnaire. The questionnaire included five sections: demographic, work-life, career plan, job satisfaction, and assessment of work environment. Analysis included univariate and bivariate (chi-square, Student's t-test and ANOVA) tests to describe the respondents and examine the significance between nurses' characteristics and their intent to stay. A logistic regression model was constructed to identify factors associated with nurses' intent to stay in underserved areas.

RESULTS

A total of 857 nurses from 63 Primary Healthcare (PHC) centers and hospitals responded to the questionnaire (75.5% response rate). Only 35.1% of nurses indicated their intent to stay in their current job over the coming one to three years. Surveyed nurses were most satisfied with relationship with co-workers and least satisfied with extrinsic rewards. Rural nurses working in PHC centers were more satisfied than their hospital counterparts on all aspects of work and had significantly higher intention to stay (62.5% compared to 31.5% in hospitals, P < 0.001). Regression analysis revealed that nurses less likely to report intent to stay were younger, unmarried, with less years of work experience and were not working towards a higher degree. Analysis reveals a directly proportional relationship between nurses' reported job satisfaction and their intent to stay.

CONCLUSION

This study reveals poor retention of nurses in rural and underserved areas in Lebanon, especially in the hospital sector. The status quo is disquieting as it reflects an unstable and dissatisfied nursing workforce. Developing targeted retention strategies for younger nurses and those working in hospitals as well as the offering of professional development opportunities and devising an incentive scheme targeting rural nurses is pivotal to enhance nurses' job satisfaction and retention in rural settings.

Association between dietary patterns and the risk of metabolic syndrome among Lebanese adults

PURPOSE

The main objective of this study was to evaluate the association between dietary patterns and the metabolic syndrome (MetS) and its metabolic abnormalities among Lebanese adults, using data from a national nutrition survey.

METHODS

A cross-sectional analysis involving adults aged ≥ 18 years (n = 323) with no prior history of chronic diseases was conducted. Participants completed a brief sociodemographic and 61-item food frequency questionnaire. Anthropometric measurements and fasting blood samples were also obtained. The International Diabetes Federation criteria were used to classify study participants with the metabolic syndrome. Dietary patterns were identified by factor analysis. Multivariate logistic regression analysis was used to evaluate the associations of extracted patterns with MetS and its metabolic abnormalities.

RESULTS

Out of 323 participants, 112 (34.6%) were classified as having MetS. Three dietary patterns were identified: "Fast Food/Dessert," "Traditional Lebanese," and "High Protein." Compared with participants in the lowest quintile of the Fast Food/Dessert pattern, those in the highest quintile had significantly higher odds for MetS (OR, 3.13; 95% CI: 1.36-7.22) and hyperglycemia (OR, 3.81; 95% CI: 159-9.14). Subjects with the highest intake of the High Protein pattern had an increased risk for hypertension (OR, 2.98; 95% CI: 1.26-7.02). The Traditional Lebanese pattern showed no association with MetS or its components.

CONCLUSIONS

The findings of this study demonstrate a positive association of the Fast Food/Dessert pattern with MetS and hyperglycemia among Lebanese adults. These results may guide the development of improved preventive nutrition interventions in this adult population.

Evaluation of heavy metals content in dietary supplements in Lebanon

BACKGROUND

The consumption of dietary supplements is widely spread and on the rise. These dietary supplements are generally used without prescriptions, proper counseling or any awareness of their health risk. The current study aimed at analyzing the metals in 33 samples of imported dietary supplements highly consumed by the Lebanese population, using 3 different techniques, to ensure the safety and increase the awareness of the citizen to benefit from these dietary supplements.

RESULTS

Some samples had levels of metals above their maximum allowable levels (Fe: 24%, Zn: 33%, Mn: 27%, Se: 15%, Mo: 12% of samples), but did not pose any health risk because they were below permitted daily exposure limit and recommended daily allowance except for Fe in 6% of the samples. On the other hand, 34% of the samples had Cu levels above allowable limit where 18% of them were above their permitted daily exposure and recommended daily allowance. In contrast, all samples had concentration of Cr, Hg, and Pb below allowable limits and daily exposure. Whereas, 30% of analyzed samples had levels of Cd above allowable levels, and were statistically correlated with Ca, and Zn essential minerals. Similarly 62% of the samples had levels of As above allowable limits and As levels were associated with Fe and Mn essential minerals.

CONCLUSION

Dietary supplements consumed as essential nutrients for their Ca, Zn, Fe and Mn content should be monitored for toxic metal levels due to their natural geochemical association with these essential metals to provide citizens the safe allowable amounts.

Sexual stigma, psychological well-being and social engagement among men who have sex with men in Beirut, Lebanon

This qualitative study sought to explore sexual identity development among men who have sex with men in Beirut, Lebanon; the stigma experienced by these men; and how their psychological well-being and social engagement are shaped by how they cope with this stigma. Semi-structured interviews were conducted with 31 men who have sex with men and content analysis was used to identify emergent themes. While many men reported feeling very comfortable with their sexual orientation and had disclosed their sexual orientation to family, most men struggled at least somewhat with their sexuality, often because of perceived stigma from others and internal religious conflict about the immorality of homosexuality. Most participants described experiencing verbal harassment or ridicule or being treated as different or lesser than in social relationships with friends or family. Mechanisms for coping with stigma included social avoidance (trying to pass as heterosexual and limiting interaction with men who have sex with men to the internet) or withdrawal from relationships in an attempt to limit exposure to stigma. Findings suggest that effective coping with both internal and external sexual stigma is central to the psychological well-being and social engagement of men who have sex with men in Beirut, much as has been found in Western gay communities.

Alcohol and Illegal Drug Use Behaviors and Prescription Opioids Use: How do Nonmedical and Medical Users Compare, and Does Motive to Use Really Matter?

BACKGROUND/AIMS

This study compares illegal drug and alcohol use behaviors between medical and nonmedical users of prescription opioids (PO) and nonmedical users with distinct motives to use.

METHOD

An ethically approved cross-sectional study (2010) was conducted on a representative sample of private university students (n = 570), using a self-filled anonymous questionnaire.

RESULTS

About 25% reported using PO only medically and 15% nonmedically. The prevalence of alcohol and illegal drug use was consistently higher among nonmedical than medical PO users. Adjusting for age and gender, lifetime medical users of PO were more likely to use marijuana only (OR = 1.8, 95% CI: 1.1, 2.8), while nonmedical users were at higher odds of using marijuana, ecstasy, cocaine/crack, and alcohol problematically. Compared to nonusers, students who took PO nonmedically for nontherapeutic reasons were more likely to use various illegal drugs, but nonmedical users who took PO to relieve pain/help in sleep were only more likely to use marijuana (OR = 2.5, 95% CI: 1.1, 5.4) and alcohol (e.g. alcohol abuse; OR = 3.8, 95% CI: = 1.4, 10.1).

CONCLUSION

Youth who use PO nonmedically to self-treat have a different alcohol and illegal drug-using profile than those who take it for nontherapeutic reasons.

Informal politics and inequity of access to health care in Lebanon

INTRODUCTION

Despite the importance of political institutions in shaping the social environment, the causal impact of politics on health care access and inequalities has been understudied. Even when considered, research tends to focus on the effects of formal macro-political institutions such as the welfare state. We investigate how micro-politics and informal institutions affect access to care.

METHODS

This study uses a mixed-methods approach, combining findings from a household survey (n = 1789) and qualitative interviews (n = 310) in Lebanon. Multivariate logistic regression was employed in the analysis of the survey to examine the effect of political activism on access to health care while controlling for age, sex, socioeconomic status, religious commitment and piety.

RESULTS

We note a significantly positive association between political activism and the probability of receiving health aid (p < .001), with an OR of 4.0 when comparing individuals with the highest political activity to those least active in our sample. Interviews with key informants also reveal that, although a form of "universal coverage" exists in Lebanon whereby any citizen is eligible for coverage of hospitalization fees and treatments, in practice, access to health services is used by political parties and politicians as a deliberate strategy to gain and reward political support from individuals and their families.

CONCLUSIONS

Individuals with higher political activism have better access to health services than others. Informal, micro-level political institutions can have an important impact on health care access and utilization, with potentially detrimental effects on the least politically connected. A truly universal health care system that provides access based on medical need rather than political affiliation is needed to help to alleviate growing health disparities in the Lebanese population.

Involving the health care system in domestic violence: what women want

PURPOSE Domestic violence is prevalent among women using primary health care services in Lebanon and has a negative effect on their health, yet physicians are not inquiring about it. In this study, we explored the attitudes of these women regarding involving the health care system in domestic violence management. METHODS We undertook a qualitative focus group study. Health care professionals in 6 primary health care centers routinely screened women for domestic violence using the HITS (Hurt, Insult, Threaten, Scream) instrument. At each center, 12 women who were screened (regardless of the result) were recruited to participate in a focus group discussion. RESULTS Most of the 72 women encouraged involvement of the health care system in the management of domestic violence and considered it to be a "socially accepted way to break the silence." Women expected health care professionals to have an "active conscience"; to be open minded, ready to listen, and unhurried; and to respect confidentiality. Additionally, they recommended mass media and community awareness campaigns focusing on family relationships to address domestic violence. CONCLUSIONS Addressing domestic violence through the health care system, if done properly, may be socially acceptable and nonoffensive even to women living in conservative societies such as Lebanon. The women in this study described characteristics of health professionals that would be conducive to screening and that could be extrapolated to the health care of immigrant Arab women.

Prevalence and patterns of commonly abused psychoactive prescription drugs in a sample of university students from Lebanon: an opportunity for cross-cultural comparisons

BACKGROUND

Concerns about psychoactive prescription drug abuse among youth are growing worldwide, but the majority of published studies remain from the US and Canada impeding cross-cultural comparisons. This study examines the prevalence, sources, motivations and substance-use correlates of commonly abused medications among youth from Lebanon.

METHODS

An IRB-approved cross-sectional study was conducted (May 2010) at the American University of Beirut. Proportionate cluster sampling was used to generate a representative sample of AUB students (n=570). A self-filled anonymous questionnaire was administered.

RESULTS

Lifetime medical and nonmedical prevalence of medications were (respectively): pain (36.9%, 15.1%), anxiety (8.3%, 4.6%), sleeping (6.5%, 5.8%) and stimulants (2.6%, 3.5%). Gender differences were not observed. Lebanese were least likely to report non-medical use. Nonmedical users mostly used the drugs for their intended purpose (e.g., sleeping to help in sleep, stimulants to increase alertness). Parents and pharmacists (without a doctor's prescription) were the top two sources of all medications, except for stimulants (friends predominated). Diversion was observed in about 20% of the medical users. Lifetime marijuana users and past year alcohol abusers were three times as likely to use any prescription drug nonmedically.

CONCLUSIONS

In Lebanon, as in Western cultures, a considerable proportion of youth may be self-medicating. The absence of medical supervision coupled with motivations such as "to get high" renders this issue a high priority on the national youth agenda. Besides larger more comprehensive surveys, the findings signal the immediate need to reinforce relevant policies, and raise awareness among youth, parents, health professionals and other stakeholders.

Maternal cultural participation and child health status in a Middle Eastern context: evidence from an urban health study

BACKGROUND

The negative effect of poverty on child health has been well established. However, rapid urbanization in developing countries prompts new research questions relating to socio-cultural practices and other related variables in these settings.

OBJECTIVE

To examine the association between maternal cultural participation and child health status in impoverished neighbourhoods of Beirut, Lebanon.

METHODS

A cross-sectional survey of 1241 mothers with children aged less than 5 years was conducted from randomly selected households in three impoverished neighbourhoods of diverse ethnic and religious make-up. The outcome variable was child health status (good/bad) as assessed by the mother. Maternal variables, including cultural participation, education, demographic and environmental/structural factors, were studied. Descriptive statistics and bivariate associations were provided using Pearson's chi-square tests. Unadjusted and adjusted odds ratios were then obtained from binary logistic regression models.

RESULTS

Two indicators of maternal cultural participation, namely watching entertaining television and attending movies/art exhibitions, were found to be significantly associated with child health status after controlling for other risk factors. The quality of water, the quality of local health services and maternal education were also significantly associated with child health status. Household income, child gender and household dampness had no significant association with child health status in this context.

CONCLUSION

Maternal cultural participation was a significant predictor of child health status in impoverished urban communities. Improving child health through culturally focused interventions for mothers, especially in deprived areas, may be greatly important.

Collecting population-based perinatal data efficiently: the example of the Lebanese National Perinatal Survey

We describe the methodology and the main results of the Lebanese perinatal health survey. The survey was carried out during two consecutive weeks in autumn 1999 and spring 2000, with the aim of obtaining a minimum data set on all births occurring during a short period of time. All live births and stillbirths occurring during these periods in medical settings were recorded. The sample included 5231 women and 5333 newborns. Data were obtained from medical records and by interviewing the women in hospital after delivery. All maternity units and birth centres agreed to participate. Maternal characteristics, medical care during pregnancy and delivery, and pregnancy outcome were similar for the two study periods. However, gestational age distribution differed between the two periods. In total, 9.0% of infants were born < 37 weeks of gestation and 7.0% weighed < 2500 g at birth. Wide regional variations were observed for many indicators of health, care and risk factors. For instance, the caesarean section rate varied from 16.2% in the North Region to 28.0% in Beirut. The survey protocol was successfully applied in Lebanon and may be useful in other countries that have a relatively well-developed healthcare system, but few sources of reliable population-based statistics on health and medical care. This type of survey may also be an appropriate instrument for collecting additional data for health policy evaluations.

Cultural capital and self-rated health in low income women: evidence from the Urban Health Study, Beirut, Lebanon

This paper examines the association between cultural capital and self-rated psychosocial health among poor, ever-married Lebanese women living in an urban context. Both self-rated general and mental health status were assessed using data from a cross-sectional survey of 1,869 women conducted in 2003. Associations between self-rated general and mental health status and cultural capital were obtained using chi (2) tests and odds ratios from binary logistic regression models. Cultural capital had significant associations with self-perceived general and mental health status net of the effects of social capital, SES, demographics, community and health risk factors. For example, the odds ratios for poor general and mental health associated with low cultural capital were 4.5 (CI: 2.95-6.95) and 2.9 (CI: 2.09-4.05), respectively, as compared to participants with high cultural capital. As expected, health risk factors were significantly associated with both measures of health status. However, demographic and community variables were associated with general health but not with mental health status. The findings pertaining to social capital and measures of SES were mixed. Cultural capital was a powerful and significant predictor of self-perceived general and mental health among women living in poor urban communities.

Psychological distress among marginalized women in the outskirts of beirut: determinants and association with health perception

The objective of this study was to determine the prevalence of psychological distress (PD) and its determinants in under-privileged women in the outskirts of Beirut, Lebanon. A cross-sectional survey of 1,869 ever-married women aged 15-59 was carried out. PD levels were determined using the 12-item General Health Questionnaire (Appendix). Health status, living conditions, social support, and physical symptoms as reported by women were recorded. Logistic regression was used to test the independent effect of each variable on PD. 46.6% of women had PD. Psychologically distressed women had more children, less education, lower income, less social support, an uncomfortable relationship with their husband, participated in the labor force and were more likely to reside in a predominantly Moslem community. Reporting a health or living problem were significant predictors of PD. The presence of limb, back and stomach pain, and headache were associated with PD. Compared to similar populations in other countries, our sample had a high prevalence of mental distress.

Demographic and psychosocial profile of smoking among pregnant women in Lebanon: public health implications

OBJECTIVES

To assess the prevalence and determinants of smoking prior to and during pregnancy in Lebanon.

METHODS

A cross-sectional study using two structured instruments. One instrument included information on demographic characteristics, smoking patterns in the index pregnancy and previous pregnancies, use of prenatal health services, stressful life events, and social support during pregnancy. The second was the Arabic General Health Questionnaire (GHQ-12). Women who delivered in 11 randomly selected hospitals in Beirut and its suburbs within 24 hours were asked to consent to participate in the study. The total sample interviewed was 576 women.

RESULTS

The prevalence of pre-pregnancy smoking was 32% and 20% for smoking in pregnancy. Considering argileh smoking, the prevalence of tobacco use in pregnancy increased to 27% in Beirut and 25% in the suburbs. Pre-pregnancy smoking was associated with older maternal age [OR = 1.08, 95% CI (1.03, 1.14)], low and medium education [OR = 2.22, 95% CI (1.22,4.04)], increased psychiatric distress [OR = 3.11, 95% CI (1.77,5.46)], and a husband who smoked [OR = 5.00, 95% CI (2.98,8.39)]. Continued smoking during pregnancy was associated with low and medium education [OR = 3.77, 95% CI (1.31, 10.8)], younger age [OR = 1.11, 95% CI (1.02-1.20)], and a heavy pre-pregnancy smoking pattern [OR = 13.9, 95% CI (1.40,137.4)].

CONCLUSION

Policies and programs to eliminate or reduce smoking during pregnancy should be targeted toward young and less educated females and involving the spouse. Obstetricians should promote smoking cessation during pregnancy using evidence-based methods.

Quality of life in rural and urban populations in Lebanon using SF-36 health survey

BACKGROUND

Measuring health status in a population is important for the evaluation of interventions and the prediction of health and social care needs. Quality of life (QoL) studies are an essential complement to medical evaluation but most of the tools available in this area are in English. In order to evaluated QoL in rural and urban areas in Lebanon, the short form 36 health survey (SF-36) was adapted into Arabic.

METHODS

SF-36 was administered in a cross-sectional study, to collect sociodemographic and environmental variables as well as self reported morbidity. We analysed a representative sample containing 1632 subjects, from whom we randomly picked 524 subjects aged 14 years and over. The translation, cultural adaptation and validation of the SF-36 followed the International Quality of Life Assessment methodology. Multivariate analysis (generalized linear model) was performed to test the effect of habitat (rural on urban areas) on all domains of the SF-36.

RESULTS

The rate of missing data is very low (0.23% of items). Item level validation supported the assumptions underlying Likert scoring. SF-36 scale scores showed wide variability and acceptable internal consistency (Cronbach's alpha >0.70), factor analysis yielded patterns of factor correlation comparable to that found in the U.S.A and France. Patients resident in rural areas had higher vitality scores than those in urban areas. Older people reported more satisfaction with some domains of life than younger people, except for physical functioning. The QoL of women is poorer than men; certain symptoms and morbidity independently influence the domains of SF-36 in this population.

CONCLUSION

The results support the validity of the SF-36 Arabic version. Habitat has a minor influence on QoL, women had a poor QoL, and health problems had differential impact on QoL.

Endemic gastrointestinal anthrax in 1960s Lebanon: clinical manifestations and surgical findings

Anthrax is an ancient disease caused by the gram-positive Bacillus anthracis; recently, it has gained much attention because of its potential use in biologic warfare. Anthrax infection occurs in three forms: cutaneous, inhalational, and gastrointestinal. The last type results from ingestion of poorly cooked contaminated meat. Intestinal anthrax was widely known in Lebanon in the 1960s, when a series of >100 cases were observed in the Bekaa Valley. We describe some of these cases, introduce the concept of the surgical management of advanced intestinal anthrax, and describe some of the approaches for treatment.