Smoking cessation counselling patterns in cancer patients - survey of Lebanese physicians.

Introduction: Tobacco smoking is a known risk factor for cancer development and smoking cessation can lower this risk and improve outcomes in some cancer patients. Despite that, many cancer patients do not quit smoking after a cancer diagnosis, and smoking cessation counselling is still not routinely provided in cancer care. The aim of this study is to examine patterns in smoking cessation counselling to cancer patients by their treating physicians. Methods: A self-administered, web-based (mobile-friendly), anonymous questionnaire was developed on LimeSurvey and sent by e-mail to Lebanese physicians of different specialties between June 2020 and January 2022. Data were analysed using SPSS and associations between the different items were determined using the χ2 test. Results: A total of 146 physicians filled out the questionnaire. Almost all physicians ask cancer patients about their smoking status, but only 45.9% provide smoking cessation counselling, and only 24% refer patients to smoking cessation counselling programs. Only 27.4% of all respondents have received formal smoking cessation training, and only 27.4% feel capable of providing smoking cessation counselling in their clinic. Specifically, family medicine physicians were more likely to provide smoking cessation counselling in the clinic (69%), more likely to refer patients to a smoking cessation counselling program (44%), and more likely to have received formal smoking cessation counselling training (67%) and more likely to feel capable of providing smoking cessation counselling (93%). Lack of training, lack of knowledge of available programs and the lack of availability of enough programs are leading obstacles contributing to low rates of smoking cessation counselling in cancer patients as reported by the physicians. Conclusion: Our data reveals a deficiency in smoking cessation counselling and referral of cancer patients to smoking cessation counselling programs in our region. This highlights the need for dedicated smoking cessation counselling training for practicing physicians and physicians in training.

Preoperative predictors of prolonged length of stay in radical cystectomy: a retrospective study using the American College of Surgeons-National Surgical Quality Improvement Program Dataset.

Background: Radical cystectomy (RC) is considered a complex procedure that entails significant morbidity and mortality. Objectives: We aimed to determine pre-operative patient characteristics that help predict a prolonged length of hospital stay (PLOS) following RC. Design and Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was used to select patients who underwent RC between the years 2011 and 2020. Prolonged length of stay was defined as a hospital stay ⩾9 days. We compared patient demographics, pre-operative labs, surgical characteristics, and medical history between patients with or without PLOS. Multivariable logistic regression models controlling for pre-operative characteristics and propensity score matching for post-operative complications were conducted to control for possible confounders. Results: The analysis yielded details of 19,158 RC patients of which 6007 (31%) patients had a PLOS. Patients with PLOS were more likely to have post-operative complications that could serve as predictors for the PLOS rather than their pre-operative characteristics. Hence, we matched our cohort for these complications. After matching, patient pre-operative characteristics that predict PLOS included female gender (Odds Ratio (OR) = 5.91), 10-year increase in age (OR = 1.15), non-White race (OR = 1.98), partially or totally dependent functional health status (OR = 2.86), bleeding disorders (OR = 4.67), congestive heart failure (OR = 1.59), pre-operative transfusion (OR = 3.03), and a 20-min increase in operative time (OR = 1.01) (p < 0.046). Conclusion: Patient demographics and pre-operative factors can help predict PLOS in RC patients. These predictors could serve as tools for patient counseling and risk stratification.

Concurrent radical cystectomy and nephroureterectomy indications and outcomes: a systematic review and comparative analysis.

Introduction: Urothelial carcinoma can arise from the urinary bladder or from the upper urinary tract. In some instances, urinary bladder cancer (UBC) and upper tract urothelial carcinoma (UTUC) can be concurrently diagnosed, necessitating a combined radical cystectomy (RC) with radical nephroureterectomy (RNU). A systematic review was done on the combined procedure exploring outcomes and indications, in addition to a comparative analysis between the combined procedure and cystectomy alone. Methods: For the systematic review, three databases (Embase, PubMed, and Cochrane) were queried, selecting only studies that included intraoperative and perioperative data. For the comparative analysis, using the NSQIP database, CPT codes for RC and RNU were used to identify two cohorts, one with RC and RNU and one with RC alone. A descriptive analysis was performed on all preoperative variables, and propensity score matching (PSM) was performed. Postoperative events were then compared between the two matched cohorts. Results: For the systematic review, 28 relevant articles were included amounting to 947 patients who underwent the combined procedure. The most common indication was synchronous multifocal disease, the most common approach was open surgery, and the most common diversion technique was using an ileal conduit. Almost 28% of patients required blood transfusion and remained in the hospital for an average of 13 days. The most common postoperative complication was prolonged paralytic ileus. For the comparative analysis, 11,759 patients were included of which 97.5% underwent RC only and 2.5% underwent the combined procedure. After PSM, the cohort that had undergone the combined procedure showed an increased risk of renal injury, increased readmission rates, and increased reoperation rates. Whereas the cohort that had undergone RC only showed an increased risk of deep venous thrombosis (DVT), sepsis, or septic shock. Conclusion: A combined RC and RNU is a treatment option for concurrent UCB and UTUC that should be cautiously utilized as it is associated with high morbidity and mortality. Patient selection, discussion of the risks and benefits of the procedure, and explanation of the available treatment options remain the most important pillars in managing patients with this complex disease.

The R.E.N.A.L score's relevance in determining perioperative and oncological outcomes: a Middle-Eastern tertiary care center experience.

Objective: The aim of this study is to evaluate the significance of the R.E.N.A.L nephrometry scoring system in predicting perioperative and oncological outcomes and determining the surgical approach of choice for kidney tumors.Patients and Methods: Our study retrospectively reviewed outcomes from the year 2002 to 2017. Mann-Whitney U test was used to compare continuous variables and chi-square test was used to compare categorical variables. Kaplan-Meier estimates and multivariable cox proportional hazard regression were performed to determine an association between the different R.E.N.A.L categories and disease recurrence or mortality. Results: A total of 325 patients underwent kidney surgery The most common R.E.N.A.L score category in our cohort study was intermediate (41.2%), followed by low, (33.2%) and high (25.5%). Patients with a high R.E.N.A.L score had worse perioperative outcomes compared to those with a low R.E.N.A.L score. High R.E.N.A.L score patients were 3 times more likely to receive blood transfusions compared to those with a low R.E.N.A.L score (19.4% vs 6.3%, p = 0.018), and a statistically significant longer hospital length of stay was also observed between the two groups (median 4.5 vs 4 days, p = 0.0419). In addition, the only predictor of disease recurrence or mortality was a high R.E.N.A.L score (Hazard Ratio (HR) 3.65, 95% Confidence Interval (CI) 1.05-12.7, p = 0.041). Conclusion: Our study sheds light on the use of R.E.N.A.L nephrometry score in predicting perioperative, postoperative, and oncological outcomes. Such findings may play a role in optimizing surgical approaches and pre-operative patient counseling.

Major adverse cardiovascular events following partial nephrectomy: a procedure-specific risk index.

Introduction: Partial nephrectomy (PN) is associated with a non-negligible risk of postoperative cardiovascular morbidity and mortality. Identification of high-risk patients may enable optimization of perioperative management and consideration of alternative approaches. The authors aim to develop a procedure-specific cardiovascular risk index for PN patients and compare its performance to the widely used revised cardiac risk index (RCRI) and AUB-HAS2 cardiovascular risk index. Methods: The cohort was derived from the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) database. The primary outcome was the incidence of major adverse cardiovascular events (MACE), defined as 30-day postoperative incidence of myocardial infarction, stroke, or mortality. A multivariate logistic regression model was constructed; performance and calibration were evaluated using an ROC analysis and the Hosmer-Lemeshow test and compared to the RCRI and the AUB-HAS2 index. Results: In a cohort of 4795 patients, MACE occurred in 52 (1.1%) patients. A univariate analysis yielded 13 eligible variables for entry into the multivariate model. The final PN-A4CH model utilized six variables: Age ⩾75 years, ASA class >2, Anemia, surgical Approach, Creatinine >1.5, and history of Heart disease. Index ROC analysis provided a C-statistic of 0.81, calibration R 2 was 0.99, and sensitivity was 85%. In comparison, the RCRI and AUB-HAS2 C-statistics were 0.59 and 0.68, respectively. Conclusion: This study proposes a novel procedure-specific cardiovascular risk index. The PN-A4CH index demonstrated good predictive ability and excellent calibration using a large national database and may enable further individualization of patient care and optimization of patient selection.

Learning curve in aquablation: an international multicenter study.

OBJECTIVES: To describe and analyze the learning curve (LC) of aquablation for the treatment of benign prostatic obstruction and determine the number of cases needed to achieve acceptable surgical safety, efficiency, and efficacy. METHODS: A retrospective analysis of prospectively maintained aquablation databases from France, Lebanon, and Spain was conducted. The combined LC of three surgeons was defined by trifecta and pentafecta outcomes. Trifecta reflected efficiency and safety: operative time < 60 min, hemoglobin reduction ≤ 2 mg/dL, and no 90 day Clavien-Dindo grade ≥ 2 complications. Pentafecta reflected effectiveness: percent reduction in International Prostate Symptom Score (IPSS) and ejaculation preservation. The combined LC was plotted using a moving average with polynomial fitting. RESULTS: The cohort included 175 consecutive patients. Median (IQR) prostate volume was 70 (50-91) cc, and baseline IPSS was 23 (18-27). The achievement of trifecta exceeded 50% after 4 cases, and 70% after 50 cases. Pentafecta achievement exceeded 50% after 38 cases. Logistic regression showed significant improvement in hemoglobin reduction and ejaculation preservation. Grade ≥ 2 complication was not affected by experience, and neither was 3 month %IPSS reduction as 94% of patients showed ≥ 50% symptoms' improvement. CONCLUSION: Aquablation is associated with a quick learning curve for the defined trifecta and pentafecta outcomes. It provided effective LUTS relief and low complication rates independent of surgeon experience. Hemoglobin drop and ejaculatory function preservation were the two factors influenced by the surgeons' LC. Training to reduce operative time, standardization of hemostasis techniques, and early assistance to improve veru-protection zone planning are keys to quicker learning.

Spontaneous ureteral stone passage: a novel and comprehensive nomogram.

BACKGROUND: Ureteral stones pose a high economic and medical burden among Emergency Department (ED) admissions. Management strategies vary from expectant therapy to surgical interventions. Since predictors of ureteral spontaneous stone passage (SSP) are still not well understood, we sought to create a novel nomogram to guide management decisions. METHODS: Charts were retrospectively reviewed for patients who presented to our institution's ED with non-febrile renal colic and received a radiological diagnosis of ureteral stone ≤10 mm. Demographic, clinical, laboratory, and non-contrast CT data were collected. This novel nomogram incorporates the serum neutrophil-to-lymphocyte ratio (NLR) as a potential predictor of SSP. The model was derived from a multivariate logistic regression and was validated on a different cohort. A receiver operator characteristic (ROC) curve was constructed and the area under the curve (AUC) was computed. RESULTS: A total of 1186 patients presented to our ED between January 2010 and October 2018. We randomly divided our population into a derivation and validation cohort in one to five ratio. A stone size ≥7 mm was the strongest predictor of SSP failure; OR=9.47; 95% CI: 6.03-14.88. Similarly, a NLR≥3.14 had 2.17; (1.58-2.98) the odds of retained stone. SSP failure was also correlated with proximal position, severe hydronephrosis, and leukocyte esterase ≥75, P=0.02, P=0.05, and P=0.006, respectively. The model had an AUC of 0.804 (0.776-0.832). The nomogram was also used to compute the risk of SSP failure (AUC 0.769 [0.709-0.829]). CONCLUSIONS: Our novel nomogram can be used as a predictor for SSP and can be used clinically in decision making.

Burnout among postgraduate medical trainees in Lebanon: Potential strategies to promote wellbeing.

Objective: Burnout is a widespread issue in healthcare for many years. Lebanon combatted political and economic crises before the coronavirus disease 2019 (COVID-19) pandemic, in addition to the port explosion in August 2020. The study aimed to identify the determinants of personal burnout, patient-related burnout, and work-related burnout among postgraduate medical trainees (PGMT) and evaluate its relationship with sociodemographic characteristics. Design: A cross-sectional study utilized the Copenhagen Burnout Inventory (CBI) involving electronic, voluntary, and anonymous survey. The survey was completed by 188 PGMT including residents and fellows from all specialties and all levels of training. Results: The prevalence rates are 68.6% for personal burnout, 63.3% for work-related burnout, and 35.1% for patient-related burnout. Conclusion: Results improve our understanding of the phenomenon of burnout, and the role of program leadership in shaping the impact of burnout on training and promoting wellbeing of PGMT. Discussion focuses on providing potential wellbeing strategies for program directors to follow for mitigating burnout.

Triple-marker immunohistochemical assessment of muscle-invasive bladder cancer: Is there prognostic significance?

BACKGROUND: Bladder cancer is the ninth most common cancer worldwide, and the third most common cancer in Lebanon. Immunohistochemistry (IHC) has been used to stratify muscle-invasive bladder cancer (MIBC) into different subtypes. However, to our knowledge, there exists no study that investigates the use of this low-cost technique to predict prognosis in bladder cancer patients in our region. AIM: To examine the feasibility of low-cost triple-marker IHC assessment for MIBC subtyping in order to predict patients' survival and cisplatin sensitivity. METHODS AND RESULTS: We collected the specimens of deceased patients diagnosed with MIBC on pathology at our institution. For each case, tumor tissue blocks were retrieved and stained for hematoxylin and eosin in addition to three molecular markers by IHC: cytokeratin 5/6, cytokeratin 14 staining basal BC, and GATA3 staining luminal BC. A cut-off of ≥20% was set as positive. Kaplan-Meier curves were built, factored by BC subtype, to predict overall survival (OS), disease-specific survival (DSS), and progression-free survival (PFS). Hazard ratios in Cox regression were also created accounting for oncological factors and BC subtype. We categorized specimens as either luminal (GATA3 positive only) (n = 21; 56.7%) or as double-positive (GATA3 and basal cytokeratin 5/6 or cytokeratin 14 positive) (n = 16; 43.3%). The overall median survival was similar between the two categories (27.0 ± 4.82 months). Numbers favored luminal disease for PFS (Breslow P = .032). After adjusting for covariates, luminal molecular expression predicted PFS (0.28; [0.09-0.94]). Yet, the Cox model was not able to identify any predictors of OS or DSS. CONCLUSION: Specimens enriched with only a luminal molecular profile were more likely to exhibit cisplatin sensitivity. Despite the absence of guidelines recommending the utilization of molecular profiling in clinic practice, triple-marker IHC could serve as a potential low-cost prognostic indicator to identify patients at high risk of progression.

Risk factors for wound dehiscence following radical cystectomy: a prediction model.

OBJECTIVES: Radical cystectomy (RC) is a complex urologic procedure performed for the treatment of bladder cancer and causes significant morbidity. Wound dehiscence (WD) is a major complication associated with RC and is associated with multiple risk factors. The objectives of this study are to identify clinical risk factors for incidence of WD and develop a risk-prediction model to aid in patient risk-stratification and improvement of perioperative care. MATERIALS AND METHODS: The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) database was used to derive the study cohort. A univariate analysis provided nine variables eligible for multivariate model entry. A stepwise logistic regression analysis was conducted and refined considering clinical relevance of the variables, and then bootstrapped with 1000 samples, resulting in a five-factor model. Model performance and calibration were assessed by a receiver operated curve (ROC) analysis and the Hosmer-Lemeshow test for goodness of fit, respectively. RESULTS: A cohort of 11,703 patients was identified from years 2005 to 2017, with 342 (2.8%) incidences of WD within 30 days of operation. The final five-factor model included male gender [odds ratio (OR) = 2.5, p < 0.001], surgical site infection (OR = 6.3, p < 0.001), smoking (OR = 1.8, p < 0.001), chronic obstructive pulmonary disease (COPD) (OR = 1.9, p < 0.001), and weight class; morbidly obese patients had triple the odds of WD (OR = 2.9, p < 0.001). The ROC analysis provided a C-statistic of 0.76 and calibration R 2 was 0.99. CONCLUSION: The study yields a statistically robust and clinically beneficial five-factor model for estimation of WD incidence risk following RC, with good performance and excellent calibration. These factors may assist in identifying high-risk patients, providing preoperative counseling and thus leading to improvement in perioperative care.