Late presentations and missed opportunities among newly diagnosed HIV patients presenting to a specialty clinic in Lebanon.

Late presentation to medical care of individuals infected with the human immunodeficiency virus (HIV) is linked to poor outcomes and increased morbidity and mortality. Missed opportunities for a prompt diagnosis are frequently reported among late presenters. We aimed to estimate the proportion of late presenters and missed opportunities in diagnosis among newly diagnosed HIV-positive subjects presenting to a specialty clinic in Lebanon. This is a retrospective chart review of all newly diagnosed adult HIV-positive subjects presenting to clinic from 2012 to 2022. Demographic, laboratory, and clinical data were collected at initial HIV diagnosis or presentation to medical care. We defined late presentation as having a CD4 count < 350 or AIDS-defining event regardless of CD4 count. Advanced disease is defined as having a CD4 count below 200 cells/µL or the presence of an AIDS-defining illness, regardless of the CD4 count. A missed opportunity was defined as the presence of an indicator condition (IC) that suggests infection with HIV/AIDS during 3 years preceding the actual HIV diagnosis and not followed by a recommendation for HIV testing. The proportions for demographic, epidemiological, and clinical characteristics are calculated by excluding cases with missing information from the denominator. Our cohort included 150 subjects (92.7% males; 63.6% men who have sex with men (MSM); 33.3% heterosexuals; median age 30.5 years at diagnosis). 77 (51.3%) were late presenters and 53 (35.3% of all subjects, 68.8% of late presenters) had advanced HIV on presentation. Up to 76.5% of late presenters had a presentation with an HIV-related condition at a healthcare provider without getting HIV test within the previous 3 years. The most frequent ICs were weight loss, generalized lymphadenopathy, constitutional symptoms, and chronic idiopathic diarrhea. Overall mortality rate was 4% (6/150 individuals). All-cause mortality among those who presented with AIDS was 15.4% (6/39 subjects). In our setting, late presentations and missed opportunities for HIV diagnosis are common. In the Middle East, AIDS mortality remains high with a large gap in HIV testing. To effectively influence policies, comprehensive analyses should focus on estimating the preventable health and financial burdens of late HIV presentations. Another concern pertains to healthcare providers' attitudes and competencies.

Early Clinical Outcomes in Infants with Prenatally Diagnosed Perimembranous and Muscular Ventricular Septal Defects (VSDs).

Isolated ventricular septal defect (VSD) is often associated with good clinical outcomes. However, infants prenatally diagnosed with VSD are often recommended for delivery at tertiary care centers. The aim of our study was to determine the odds of neonatal intensive care unit (NICU) admission in infants with persistent isolated VSD and complicated VSD, where an infant is affected by VSD and other genetic/structural abnormalities. We performed a retrospective cohort study, with data collected from a single academic institution from June 2018 to March 2023. Individuals with prenatally diagnosed VSD, in the absence of any other heart defects, were included in this study. The primary outcome was admission to the NICU. Multivariable logistic regression was used to assess associations. The association between persistence of VSD and NICU admission was adjusted for maternal age, fetal genetic abnormalities, fetal extracardiac abnormalities, and gestational age at the time of delivery. The association between complicated VSD and NICU admission was adjusted for maternal age and gestational age of the infant at the time of delivery. The odds of NICU admission were similar in infants with persistent isolated VSD and VSD that closed in utero (adjusted OR 1.31, 95% CI 0.30-5.61). However, infants with complicated VSD were at increased risk of NICU admission (adjusted OR 15.52, 95% CI 2.90-82.92). The risk of NICU admission was only increased in infants whose VSD was complicated by another genetic/major structural abnormalities. Therefore, women whose infants are prenatally diagnosed with VSD alone may not require delivery at tertiary care centers.

The impact of early diagnosis of fetal single-ventricle cardiac defects on reproductive choices.

BACKGROUND: Congenital heart defects are the most common fetal anomaly. Congenital heart defects with single-ventricle cardiac defects have high mortality rates, and in pregnancies diagnosed with this condition, patients are often offered termination of pregnancy as an option. OBJECTIVE: This study aimed to investigate the relationship between gestational age at diagnosis and reproductive choices in fetuses diagnosed with single-ventricle cardiac defects. STUDY DESIGN: This was a retrospective single-center cohort study in which 158 patients with a fetal diagnosis of single-ventricle cardiac defects were reviewed. Cases were categorized as isolated or complex. Complex cases included fetuses with single-ventricle cardiac defects in addition to other fetal extracardiac anomalies or chromosomal abnormalities. RESULTS: A total of 158 patients were diagnosed with single-ventricle cardiac defects during the study period. Of those patients, 37 (23.4%) underwent termination of pregnancy, 113 (71.5%) delivered, and 8 (5.1%) had an intrauterine fetal demise. Gestational age at diagnosis and race were significant predictors of the termination decision. The median gestational age at diagnosis was earlier in the termination of pregnancy group (20.4 vs 23.6 weeks; P<.001). Pregnancies complicated by single-ventricle cardiac defects diagnosed in early gestation (11 0/7 to 14 5/7 weeks of gestation) were more likely to be terminated than pregnancies complicated by single-ventricle cardiac defects diagnosed in middle gestation (15 0/7 to 27 5/7 weeks of gestation) and late gestation (≥28 weeks of gestation) (54.2% vs 23.2% and 2.9%; P<.001). Earlier gestational age at diagnosis was correlated with earlier gestational age at termination (r=0.92; P<.001). CONCLUSION: Termination of pregnancy was more common when the single-ventricle cardiac defect was diagnosed earlier in pregnancy. This could be explained by the fact that early diagnoses allow parents to make deliberate and informed decisions.

The value of detailed first-trimester ultrasound in the era of noninvasive prenatal testing.

BACKGROUND: In 2020, the American College of Obstetricians and Gynecologists recommended noninvasive prenatal testing be offered to all patients. However, current societal guidelines in the United States do not universally recommend a detailed first-trimester ultrasound. OBJECTIVE: This study aimed to determine the additional findings identified through first-trimester ultrasound that would have otherwise been missed if noninvasive prenatal testing was used alone as a first-trimester screening method. STUDY DESIGN: This was a retrospective cohort study involving 2158 pregnant patients and 2216 fetuses that were seen at a single medical center between January 1, 2020, and December 31, 2022. All those included underwent both noninvasive prenatal testing and detailed first-trimester ultrasound between 11.0 and 13.6 weeks of gestation. Noninvasive prenatal testing results were categorized as low risk or high risk, and first-trimester ultrasound results were categorized as normal or abnormal. Abnormal first-trimester ultrasounds were further classified as first-trimester screening markers (increased nuchal translucency, absent nasal bone, tricuspid regurgitation, and ductus venosus reverse a-wave) or structural defects (the cranium, neck, heart, thorax, abdominal wall, stomach, kidneys, bladder, spine, and extremities). Descriptive statistics were used to report our findings. RESULTS: Of 2216 fetuses, 65 (3.0%) had a high-risk noninvasive prenatal testing result, whereas 2151 (97.0%) had a low-risk noninvasive prenatal testing result. Of those with a low-risk noninvasive prenatal testing result, 2035 (94.6%) had a normal first-trimester ultrasound, whereas 116 (5.4%) had at least 1 abnormal finding on first-trimester ultrasound. The most common screening marker detected within the low-risk noninvasive prenatal testing group was absent nasal bone (52/2151 [2.4%]), followed by reversed a-wave of the ductus venosus (30/2151 [1.4%]). The most common structural defect in this group was cardiac abnormality (15/2151 [0.7%]). Overall, 181 fetuses were identified as having "abnormal screening" through either a high-risk noninvasive prenatal testing result (n=65) or through a low-risk noninvasive prenatal testing result but abnormal first-trimester ultrasound (n=116). In summary, the incorporation of first-trimester ultrasound screening identified 116 additional fetuses (5.4%) that required further follow-up and surveillance than noninvasive prenatal testing alone would have identified. CONCLUSION: Detailed first-trimester ultrasound identified more fetuses with a potential abnormality than noninvasive prenatal testing alone. Therefore, first-trimester ultrasound remains a valuable screening method that should be used in combination with noninvasive prenatal testing.

Topography of the Heart: Mapping the Fetal Heart Through SlowflowHD.

SlowflowHD is a Doppler Ultrasound modality that is typically geared toward visualization of small-size vessels and low velocity blood flow. In this commentary, we emphasize the importance of implementing the use of SlowflowHD as an adjunct to traditional Doppler modalities in the echocardiography screening in both the first and second trimester. This modality carries many characteristics that allow it to overcome the limitations of our current ultrasound modalities and facilitate mapping of the entirety of the fetal heart. The clinical implications are significant in regard to earlier acquisition of diagnostic information to guide decision-making and patient counseling.

Assessing the knowledge, attitudes, and practices of graduating medical students towards sexual health in Lebanon.

OBJECTIVE: To assess the knowledge, attitudes, and practices of graduating medical students in Lebanon regarding sexual health, as well as their readiness to learn about it, and to determine the demographic and educational factors that influence our findings. METHODS: Cross-sectional study. A self-designed questionnaire exploring various components of sexual health was sent to 578 graduating medical students in Lebanon. Knowledge, attitude, and practice scores were computed and analyzed. RESULTS: The overall mean knowledge score was relatively low (2.61, range -13 to 10). A statistically significant difference was found in the mean knowledge score across religion (P = 0.028) and religiosity (P < 0.001) categories. The mean practice score also differed significantly across income groups (P = 0.010). No other significant associations were found between gender, sexuality, environment, primary source of sexual health education, or language and the mean knowledge, attitude, and practice scores. CONCLUSION: Additional standardized assessment of medical students' competences in sexual health matters through diverse research models is needed. Re-examination of existing medical curricula and inclusion of more extensive sexual health education is necessary to improve patient care.

Effectiveness and Predictors of Outcomes in a Psychiatric Day Treatment Program for Elementary-Age.

OBJECTIVE: In this study, we aimed to (1) assess the effectiveness of an intensive multimodal day treatment program in improving externalizing problems and function in elementary-age children and (2) examine 3 predictors of the treatment outcome (i.e., family functioning, baseline severity, and comorbid disorders). METHODS: The sample included 261 children (80.9% boys) between ages of 5 and 12. A retrospective chart review, from 2013 to 2018, and a prospective chart review, from 2018 to 2019, were conducted to extract all relevant data for the present study. Parents and teachers provided reports on children's externalizing problems (i.e., aggressive behavior, attention problems, and rule-breaking behavior) and their level of function across different domains. The level of family functioning was also reported by parents, while clinicians assessed children's severity of disturbance and their diagnoses at intake. RESULTS: Based on both parents' and teachers' reports, children showed significant improvement in their externalizing problems. Moreover, children showed functional improvement at home, at school, with peers, and in hobbies by the end of the program. Based on teacher's reports, children with lower level of severity showed less improvement in their attention problems, and those with comorbid developmental problems showed less improvement in their aggressive and rule-breaking behaviors. Family functioning did not predict any treatment outcome. CONCLUSION: An intensive multimodal day treatment program was effective in reducing the symptoms of externalizing problems in elementary-age children. However, children with less severe difficulties and comorbid developmental problems showed less improvement in their externalizing problems.