Smoking Behavior among Adolescents: The Lebanese Experience with Cigarette Smoking and Waterpipe Use.

(1) Background: The study aims to assess cigarette smoking and waterpipe experimentation among Lebanese adolescent school students with respect to their gender, region, age, and socioeconomic status. (2) Methods: This is a cross-sectional study, where students between 11 to 18 years of age were included from all over Lebanon. (3) Results: A total of 1133 students were interviewed. The total proportion of adolescents who ever experimented with cigarette smoking was 24.5%. Males experimented with cigarette smoking more commonly than females (31.9% vs. 19.1%; p < 0.001). Cigarette smoking experimentation was higher among students from the Beirut area (33.6%; p < 0.001) in comparison to other regions, and among those with poor health perception (29.1% vs. 19.8%; p < 0.001) compared to students with excellent health perception. The total proportion of adolescents who ever used a waterpipe was 33.9%. Waterpipes were significantly more experimented with among males than females (40.3% vs. 29.8%; p < 0.001), and among students with bad perception about their health (39.4% vs. 28.9%; p < 0.001). Adolescents who experimented with both cigarettes and waterpipes constitute 22.2% of the studied sample. (4) Conclusions: The rate of tobacco product use is alarming and constitutes a major public health issue for adolescents that urgently needs intervention. The findings raise important policy implications for the development of cigarette smoking prevention programs for youth.

Laboratory assays of VWF activity and use of desmopressin trials in the diagnosis of VWD: a systematic review and meta-analysis.

von Willebrand Disease (VWD) is associated with significant morbidity because of excessive bleeding. Early diagnosis and treatment are important to prevent and treat these symptoms. We systematically reviewed the accuracy of any von Willebrand factor (VWF) activity assay in the diagnosis and classification of patients for VWD. We searched Cochrane Central, MEDLINE, and EMBASE for eligible studies. The risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and the certainty of evidence using the GRADE framework. We pooled estimates of sensitivity and specificity. The review included 77 studies that evaluated the use of newer tests of VWF platelet binding activity (VWF:GPIbR, VWF:GPIbM) and VWF:RCo for the diagnosis of VWD (13 studies), VWF propeptide to VWF:Ag ratio, and desmopressin trial for the diagnosis of type 1C VWD (5 studies), VWF multimer analysis and VWF:CB/VWF:Ag ratio for the classification of type 2 VWD (11 studies), genetic testing and ristocetin-induced platelet aggregation to diagnose type 2B VWD (14 studies), genetic testing and FVIII:VWF binding to diagnose type 2N VWD (17 studies). Based on available diagnostic test accuracy, there appear to be comparable test accuracy results between newer tests of platelet binding activity of VWF function and VWF:RCo. The findings of these reviews support VWF multimer analysis or VWF:CB/VWF:Ag to diagnose type 2 VWD. The desmopressin trial test with 1- and 4-hour postinfusion blood work is the test of choice to confirm increased VWF clearance in patients with suspected VWD type 1C. Additionally, genetic testing is most useful in diagnosing type 2B VWD and has a role in the diagnostic algorithm of suspected type 2N VWD.

Current State of Evidence on Kidney Transplantation: How Fragile Are the Results?

BACKGROUND: The study aims is to use the fragility index (FI) to examine the strength of evidence of randomized controlled trials (RCTs) published in the last decade on kidney transplantation. METHODS: We searched MEDLINE for studies on kidney transplantation. We included the RCTs that compared 2 groups with 1:1 randomization and reported significant P values (<0.05) for a dichotomous outcome and were published in the top 10 transplant journals. We calculated the FI; a calculation used to determine the minimum number of subjects needed to change from a nonevent to an event to make the study results nonsignificant (P ≥ 0.05). RESULTS: Fifty-seven RCTs met our inclusion criteria. The median sample size was 100 participants in each arm, the median number of events was 16 (interquartile range, 8-30) in the intervention group. Among the included trials, 79% were industry-funded, 93% involved medications, and the majority were open label. The median FI was 3 (interquartile range, 1-11). In 43% of the trials, the number of patients reported lost to follow-up was higher than or equal to the FI. Only 4% of the RCTs imputed a value for the missing dichotomous outcome. Furthermore, the median number of subjects who discontinued the trial because of adverse effects was 21, which was greater than the FI in 60% of the RCTs. CONCLUSIONS: The arbitrary classification of results into "significant" and "nonsignificant" based on P value <0.05 should perhaps be interpreted with the help of other statistical parameters and FI is one of them.

von Willebrand factor levels in the diagnosis of von Willebrand disease: a systematic review and meta-analysis.

von Willebrand disease (VWD) is associated with significant morbidity as a result of excessive mucocutaneous bleeding. Early diagnosis and treatment are important to prevent and treat these symptoms. We systematically reviewed the accuracy of diagnostic tests using different cutoff values of von Willebrand factor antigen (VWF:Ag) and platelet-dependent von Willebrand factor (VWF) activity assays in the diagnosis of VWD. We searched Cochrane Central Register for Controlled Trials, MEDLINE, and Embase databases for eligible studies. We pooled estimates of sensitivity and specificity and reported patient-important outcomes when relevant. This review included 21 studies that evaluated VWD diagnosis. The results showed low certainty in the evidence for a net health benefit from reconsidering the diagnosis of VWD vs removing the disease diagnosis in patients with VWF levels that have normalized with age. For the diagnosis of type 1 VWD, VWF sequence variants were detected in 75% to 82% of patients with VWF:Ag < 0.30 IU/mL and in 44% to 60% of patients with VWF:Ag between 0.30 and 0.50 IU/mL. A sensitivity of 0.90 (95% confidence interval [CI], 0.83-0.94) and a specificity of 0.91 (95% CI, 0.76-0.97) were observed for a platelet-dependent VWF activity/VWF:Ag ratio < 0.7 in detecting type 2 VWD (moderate certainty in the test accuracy results). VWF:Ag and platelet-dependent activity are continuous variables that are associated with an increase in bleeding risk with decreasing levels. This systematic review shows that using a VWF activity/VWF:Ag ratio < 0.7 vs lower cutoff levels in patients with an abnormal initial VWD screen is more accurate for the diagnosis of type 2 VWD.

Surgical management of patients with von Willebrand disease: summary of 2 systematic reviews of the literature.

von Willebrand disease (VWD) is the most common inherited bleeding disorder. The management of patients with VWD who are undergoing surgeries is crucial to prevent bleeding complications. We systematically summarized the evidence on the management of patients with VWD who are undergoing major and minor surgeries to support the development of practice guidelines. We searched Medline and EMBASE from inception through October 2019 for randomized clinical trials (RCTs), comparative observational studies, and case series that compared maintaining factor VIII (FVIII) levels or von Willebrand factor (VWF) levels at >0.50 IU/mL for at least 3 days in patients undergoing major surgery, and those with options for perioperative management of patients undergoing minor surgery. Two authors screened and abstracted data and assessed the risk of bias. We conducted meta-analyses when possible. We evaluated the certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. We included 7 case series for major surgeries and 2 RCTs and 12 case series for minor surgeries. Very-low-certainty evidence showed that maintaining FVIII levels or VWF levels of >0.50 IU/mL for at least 3 consecutive days showed excellent hemostatic efficacy (as labeled by the researchers) after 74% to 100% of major surgeries. Low- to very-low-certainty evidence showed that prescribing tranexamic acid and increasing VWF levels to 0.50 IU/mL resulted in fewer bleeding complications after minor procedures compared with increasing VWF levels to 0.50 IU/mL alone. Given the low-quality evidence for guiding management decisions, a shared-decision model leading to individualized therapy plans will be important in patients with VWD who are undergoing surgical and invasive procedures.

Bleeding assessment tools in the diagnosis of VWD in adults and children: a systematic review and meta-analysis of test accuracy.

Von Willebrand disease (VWD) can be associated with significant morbidity. Patients with VWD can experience bruising, mucocutaneous bleeding, and bleeding after dental and surgical procedures. Early diagnosis and treatment are important to minimize the risk of these complications. Several bleeding assessment tools (BATs) have been used to quantify bleeding symptoms as a screening tool for VWD. We systematically reviewed diagnostic test accuracy results of BATs to screen patients for VWD. We searched Cochrane Central, MEDLINE, and EMBASE for eligible studies, reference lists of relevant reviews, registered trials, and relevant conference proceedings. Two investigators screened and abstracted data. Risk of bias was assessed using the revised tool for the quality assessment of diagnostic accuracy studies and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We pooled estimates of sensitivity and specificity. The review included 7 cohort studies that evaluated the use of BATs to screen adult and pediatric patients for VWD. The pooled estimates for sensitivity and specificity were 75% (95% confidence interval, 66-83) and 54% (29-77), respectively. Certainty of evidence varied from moderate to high. This systematic review provides accuracy estimates for validated BATs as a screening modality for VWD. A BAT is a useful initial screening test to determine who needs specific blood testing. The pretest probability of VWD (often determined by the clinical setting/patient population), along with sensitivity and specificity estimates, will influence patient management.

A cross-sectional survey on community pharmacists readiness to fight COVID-19 in a developing country: knowledge, attitude, and practice in Lebanon.

BACKGROUND: Lebanon, a developing Middle Eastern country, was hit by the COVID-19 pandemic that occurred amid a severe national economic crisis. Community pharmacists are responsible for dispensing appropriate medications and products in addition to counseling, informing and educating the public, and promoting disease prevention and infection control. OBJECTIVE: This study aimed to assess community pharmacists' knowledge, attitude, and practice towards the COVID-19 pandemic and evaluate behavior changes and safety measures. METHODS: An anonymous and standardized online questionnaire in English was disseminated via social media platforms to Lebanese community pharmacists. The questionnaire consisted of 95 items designed as Likert-scales and multiple-choice questions divided into four different sections: socio-demographic characteristics, knowledge-based, attitude-based, and pharmacy practice questions. Descriptive statistical analysis was used to summarize the demographic characteristics, and indices were created for knowledge, attitude, and practice by computing the correct answers for each section. RESULTS: A total of 310 questionnaires were completed. Around 61% have expressed their fear of getting infected with COVID-19 due to occupational exposure. The respondents were able to answer 80-90% of the knowledge-based questions of the survey. A more careful/anxious attitude, but not knowledge, was associated with overall better practice (p = 0.03). Also, respondents stated that they are dispensing protective equipment items such as masks (87%), gloves (60%), and sanitizers (77%) in small quantities due to limited availability. CONCLUSION: Our findings revealed an adequate level of knowledge and good practice towards COVID-19 among Lebanese community pharmacists. Their fears of contracting the virus and compromising the safety of those around them are justified. However, their supply of protective equipment is limited.

Economic Burden of Urinary Tract Infections From Antibiotic-Resistant Escherichia coli Among Hospitalized Adult Patients in Lebanon: A Prospective Cohort Study.

OBJECTIVES: The rising incidence of urinary tract infections (UTIs) attributable to Escherichia coli resistant isolates is becoming a serious public health concern. Although global rates of infection vary considerably by region, the growing prevalence of this uropathogen has been associated with a high economic burden and health strain. This study aims: (1) to estimate the differences in clinical and economic outcomes between 2 groups of adult hospitalized patients with UTIs from E. coli resistant and susceptible bacteria and (2) to investigate drivers of this cost from a payer's perspective. METHODS: A prospective multicenter cohort study was conducted in 10 hospitals in Lebanon. The cost analysis followed a bottom-up microcosting approach; a linear regression was constructed to evaluate the predictors of hospitalization costs and a Cox proportional hazards model was used to estimate the impact of resistance on length of stay (LOS) and in-hospital mortality. RESULTS: Out of 467 inpatients, 250 cases were because of resistant E. coli isolates. Results showed that patients with resistant uropathogens had 29% higher mean total hospitalization costs ($3429 vs $2651; P = .004), and an extended median LOS (6 days vs 5 days; P = .020) compared with susceptible cohorts. The selection of resistant bacteria and the Charlson comorbidity index predicted higher total hospitalization costs and in-hospital mortality. CONCLUSION: In an era of increased pressure for cost containment, this study showed the burden of treating UTIs resulting from resistant bacteria. The results can inform cost-effectiveness analyses that intend to evaluate the benefit of a national action plan aimed at decreasing the impact of antibiotic resistance.

Economic Burden of Urinary Tract Infections From Antibiotic-Resistant Escherichia coli Among Hospitalized Adult Patients in Lebanon: A Prospective Cohort Study.

OBJECTIVES: The rising incidence of urinary tract infections (UTIs) attributable to Escherichia coli resistant isolates is becoming a serious public health concern. Although global rates of infection vary considerably by region, the growing prevalence of this uropathogen has been associated with a high economic burden and health strain. This study aims: (1) to estimate the differences in clinical and economic outcomes between 2 groups of adult hospitalized patients with UTIs from E. coli resistant and susceptible bacteria and (2) to investigate drivers of this cost from a payer's perspective. METHODS: A prospective multicenter cohort study was conducted in 10 hospitals in Lebanon. The cost analysis followed a bottom-up microcosting approach; a linear regression was constructed to evaluate the predictors of hospitalization costs and a Cox proportional hazards model was used to estimate the impact of resistance on length of stay (LOS) and in-hospital mortality. RESULTS: Out of 467 inpatients, 250 cases were because of resistant E. coli isolates. Results showed that patients with resistant uropathogens had 29% higher mean total hospitalization costs ($3429 vs $2651; P = .004), and an extended median LOS (6 days vs 5 days; P = .020) compared with susceptible cohorts. The selection of resistant bacteria and the Charlson comorbidity index predicted higher total hospitalization costs and in-hospital mortality. CONCLUSION: In an era of increased pressure for cost containment, this study showed the burden of treating UTIs resulting from resistant bacteria. The results can inform cost-effectiveness analyses that intend to evaluate the benefit of a national action plan aimed at decreasing the impact of antibiotic resistance.

Periacetabular triple osteotomy by single anterior approach for children under 6-years-old with severe acetabular deficiency: prevention of retroversion and anterior impingement.

The aim of this study was to perform periacetabular triple osteotomy (PATO) in children under 6-years-old with severe acetabular deficiency aiming to obtain important correction and avoid excessive pressure on epiphysis, anterior overcorrection and acetabular retroversion. This is a retrospective study of 29 PATO using single anterior approach in 24 patients under 6-years-old with dysplasia of the hip. Clinical examination and radiographic evaluation were done pre-op, post-op and at last follow-up. Computed tomography (CT) scan was obtained, comparing operated hip to contro-lateral normal hip. Clinical examination of the operated hip, at the last follow-up, showed a normal range of motion with nonsignificant difference when compared to normal hip. All hips were classified as Wicart A, and all activities were allowed. Radiographically, X-ray revealed improvement of all parameters postoperatively, with nonsignificant change compared to the last follow-up. CT-2D axial analysis demonstrated the absence of acetabular retroversion with good anterior and posterior coverage. CT-3D imaging comparing the anterior acetabular inclination, anterolateral and posterolateral inclination angles of operated hip and normal hip showed comparable results. Patients less than 6 years with severe acetabular deficiency could benefit from PATO. Performing osteotomies close to joint gave important acetabular fragment freedom, allowing an important correction. Appropriate manoeuver of reorientation avoided anterior overcorrection and acetabular retroversion, responsible for early pain and osteoarthritis. Age should not be the only criteria to choose the type of osteotomy. Level of evidence: level IV.

Reporting and Handling of Missing Participant Data in Systematic Reviews of Kidney Transplant Studies.

BACKGROUND: Participant withdrawal from clinical trials occurs for various reasons, predominantly adverse effects or intervention inefficacy. Because these missing participant data can have implications for the validity, reproducibility, and generalizability of study results, when conducting a systematic review, it is important to collect and appropriately analyze missing data information to assess its effects on the robustness of the study results. METHODS: In this methodologic survey of missing participant data reporting and handling in systematic reviews, we included meta-analyses that provided pooled estimates of at least 1 dichotomous intervention outcome of a randomized controlled trial performed in adult kidney transplant subjects. RESULTS: Eighty-three systematic reviews (17 Cochrane and 66 non-Cochrane reviews) met the inclusion criteria. The most common intervention was drugs (80%), with the majority involving immunosuppressant drugs 55% (n = 46), followed by surgery in 14% (n = 12). The median follow-up duration was 12 months (maximum, 240 mo). Intention-to-treat or modified intention-to-treat analysis was reported in 24% (n = 20) of the reviews (76% of Cochrane and 10% of non-Cochrane). Overall, the majority of systematic reviews did not quantify (90% [n = 60] non-Cochrane and 29% [n = 5] Cochrane) or include the reasons for missing participant data (88% [n = 58] non-Cochrane and 24% [n = 4] Cochrane). Eleven percent (n = 9) handled missing participant data, 5% (n = 4) justified the analytical method(s) used to handle it, and 2% (n = 2) performed a sensitivity analysis for it. CONCLUSIONS: Systematic reviews of kidney transplantation provide inadequate information on missing participant data and usually do not handle or discuss the associated risk of bias with it.

Multifocal CD4+ Primary Cutaneous Small/Medium Lymphoproliferative Disorder Successfully Treated With Low-Dose Oral Methotrexate: A Case Report.

Primary cutaneous CD4+ small/medium T-cell lymphoproliferative disorder (PCSM-LPD) is a rare indolent disorder often associated with a favourable prognosis. It typically presents as a solitary skin lesion, mainly in the head, neck, or upper trunk region. Multifocal PCSM-LPD is a rare entity, with no standard treatment approaches available. In this article, we present the case of a 56-year-old male patient with multifocal biopsy-proven PCSM-LPD that was treated with methotrexate orally at 10 mg/m2 body surface area weekly and successfully achieved full clinical resolution by the 10th week of therapy. A review of the literature indicates the efficacy of combination chemotherapy. However, due to the indolent nature of this disorder and the undesired side effects from combination chemotherapy, our treatment method involved oral methotrexate alone, and it was successful. Oral methotrexate is a potential therapeutic option in the management of multifocal PCSM-LPD and it warrants further investigations.

Experiential Education in Pharmacy Curriculum: The Lebanese International University Model.

Experiential education is an essential component of pharmacy education in order to allow intern students to experience real conditions and training opportunities in different inpatient and outpatient settings. This paper provides a description of the pharmacy practice experiences (PPEs) in the Lebanese International University (LIU) 5-year bachelor of pharmacy (BPharm) and postgraduate doctor of pharmacy (PharmD) programs; focuses on the opportunities and challenges encountered; and presents a model for experiential education in Lebanon. Learning outcomes and thus students' acquisition of predefined competencies are evaluated in actual practice settings through assessment tools. Our experiential education program aligns with the accreditation/certification criteria set by the Accreditation Council for Pharmacy Education (ACPE) and equips future pharmacists with the knowledge and skills to become major components in the healthcare team.

Is there any role for topical non-steroidal anti-inflammatory drugs in the treatment of mild to moderate musculoskeletal pain in a Lebanese community pharmacy?

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in the community pharmacy. Their systemic administration has been related to significant adverse effects. The aim of this study was to evaluate the efficacy of topical NSAIDs in managing mild to moderate musculoskeletal pain versus systemic administration or combination of both routes. METHODS: This was a prospective observational study conducted in a large Lebanese community pharmacy over a period of 5 months in 302 patients. Participants were divided into three groups according to their route of administration of NSAIDs either topically, systemically or combination of both. During follow up period, degree of pain, efficacy of NSAID therapy, side effects, onset time and duration of pain relief reported by each patient were collected by the study investigators using specific formulated questionnaire. Degree of pain was assessed using the Numeric Rating Scale (NRS-11). The efficacy of NSAID therapy was defined as 50 % reduction or more in pain. The primary outcome was to assess the efficacy between groups. The secondary outcomes were onset time, duration of pain relief and side effects between the three groups. RESULTS: A total of 149 patients were enrolled in this study. 78 patients administered topical NSAIDs, 40 administered systemic NSAIDs and 31 administered combination of both routes. Efficacy of NSAID therapy for all routes was reported in 132 participants (89 %) distributed as 64 in topical, 37 in systemic and 31 in combination. Bi-variate analysis showed no significant difference in efficacy between topical versus systemic (p = 0.99) and topical versus combination (p = 0.14). The mean onset of topical NSAIDs was significantly faster than systemic by 12.7 min (p < 0.05). The mean duration of pain relief of systemic NSAIDs was significantly longer than topical by 3 h (p < 0.05). Patients administered systemic NSAIDs (either alone or in combination) reported increase in blood pressure and gastric-upset 8 and 38 cases, respectively. CONCLUSION: There was no significant statistical difference between NSAIDs route's of administration for the treatment of mild to moderate musculoskeletal pain in Lebanese community pharmacy patients. Topical NSAIDs were fast in onset and effective in reducing pain with no significant adverse effects.

FOREFOOT ADDUCTION IN CHILDREN. Management and Treatment.

Forefoot adduction is a common condition between metatarsus adductus, Z-shaped foot and residual clubfoot. This deformity is located in a pure transverse plane at Lisfranc's joint. Isolated metatarsus adductus is corrected spontaneously for the majority of newborns. In rare uncorrected cases, it could result in Z-shaped foot with a functional hindfoot valgus to equilibrate the resistant metatarsus adductus. As well, in residual clubfoot, recurrent metatarsus adductus varus is observed, usually in children over three years. In flexible metatarsus adductus the treatment is conservative. The surgery is proposed in toddlers and after failure of conservative treatment. Procedures carried out on metatarsals gave good results on short term, but showed a high rate of recurrence and growth disturbance. Osteotomies proximal to the Lisfranc's joint: calcaneo-cuboid fusion, anterior resection of calcaneus, and opening wedge osteotomy of medial cuneiform, gave permanent correction but they act only on one of the sides of deformity. Therefore, the theory of elongated lateral column associated with a shortened medial column is crucial in dealing with this deformity: combining opening wedge osteotomy of cuneiform with closing wedge osteotomy of cuboid described by Jawish et al. in children over 4 years allows ­ in all causes of metatarsus adductus stiffness ­ a lateral shifting of forefoot. Concerning the associated heel's valgus, it is corrected in Z-shaped foot after the associated heel's valgus, it is corrected in Z-shaped foot after the double osteotomy cuneiform/cuboid. However, in complicated treated clubfoot a particular treatment for the posterior tarsal is necessary.