Predictors of moderate to severe obstructive sleep apnea in patients with lung cancer.

BACKGROUND AND OBJECTIVES: OSA is a known medical condition that is associated with several comorbidities and affect patients' quality of life. The association between OSA and lung cancer remains debated. Some studies reported increased prevalence of OSA in patients with lung cancer. We aimed to assess predictors of moderate-to-severe OSA in patients with lung cancer. METHODS: We enrolled 153 adult patients who were newly diagnosed with lung cancer. Cardiorespiratory monitoring was performed using home sleep apnea device. We carried out Univariate and multivariate logistic regression analysis on multiple parameters including age, gender, smoking status, neck circumference, waist circumference, BMI, stage and histopathology of lung cancer, presence of superior vena cava obstruction, and performance status to find out the factors that are independently associated with a diagnosis of moderate-to-severe OSA. RESULTS: Our results suggest that poor performance status is the most significant predictor of moderate to severe OSA in patients with lung cancer after controlling for important confounders. CONCLUSION: Performance status is a predictor of moderate to severe OSA in patients with lung cancer in our population of middle eastern ethnicity.

Health-related quality of life and utilities among Lebanese patients with Multiple Sclerosis: A cross-sectional study.

OBJECTIVE: This study assessed the Health-Related Quality of Life (HRQoL) and utilities of Multiple Sclerosis (MS) patients in Lebanon using generic and MS-specific QoL instruments, categorized by disease severity, and explored factors associated with HRQoL. METHODS: This was a cross-sectional, retrospective HRQoL study collecting data through face-to-face interviews using the EQ-5D-5 L and the Multiple Sclerosis International Quality of Life (MusiQoL) questionnaires. We enrolled Lebanese patients aged ≥18 years, diagnosed with MS for >6 months. Patients were categorized by disease severity using the expanded disability status scale (EDSS) scores: 0-3 (mild MS), 4-6.5 (moderate MS), and 7-9 (severe MS). Bivariate and linear regression analyses were performed to study factors associated with HRQoL. RESULTS: A total of 210 patients (mean age: 43.3 years; 65.7 % females) were included. The mean EQ-5D-5 L utility score was 0.74. This score decreased significantly with disease severity (p < 0.001 for the trend): 0.93, 0.60, and 0.32 for mild, moderate, and severe MS, respectively. The mean MusiQoL global index score was 71.33 and was significantly lower for severe MS (58.68), than for moderate (65.23) and mild (77.80), (p < 0.001 for the trend). Higher educational level, lower EDSS scores, and longer disease duration were associated significantly with a higher EQ-5D-5 L utility (R2 = 0.67), while employment, lower EDSS scores, and decrease in cognitive difficulties were associated with better MusiQoL utility (R2 = 0.46). CONCLUSIONS: This study reveals a significant and gradual deterioration in HRQoL as MS progresses, resulting in low utility scores for patients with severe MS.

Burden of obstructive sleep apnea in patients with lung cancer and its effect on performance status.

The association between lung cancer and obstructive sleep apnea has remained a matter of debate for years. Obstructive sleep apnea is thought to increase the incidence of lung cancer due to intermittent hypoxaemia and sleep fragmentation. The aim of this study is to assess the prevalence of obstructive sleep apnea in patients with lung cancer and its effect on those patients' performance status. This is a prevalence study that was conducted at Chest Diseases Department, Alexandria Main University Hospitals. We enrolled 153 patients with lung cancer. All patients underwent cardiorespiratory monitoring using a home sleep-testing device. Performance status was assessed using Karnofsky performance status scale. The study included 120 (78.4%) males and 33 (21.6%) females newly diagnosed with lung cancer. The mean age was 59.98 ± 11.11 years. Obstructive sleep apnea (apnea-hypopnea index ≥ 5) was present in 134 (87.6%) patients. Eighty-five (63.4%) patients had mild obstructive sleep apnea, 39 (29.1%) patients had moderate obstructive sleep apnea, and 10 (7.46%) patients had severe obstructive sleep apnea. Prolonged nocturnal oxygen desaturation as demonstrated by time of oxygen saturation spent below 90% (T90%) during total sleep time > 30% was present in 25 (16.3%) patients. There was a significant difference in the median value of Karnofsky performance status scale between patients with lung cancer and associated obstructive sleep apnea and those without obstructive sleep apnea. In conclusion, obstructive sleep apnea is highly prevalent among patients with lung cancer. Performance status is worse among patients with lung cancer in the presence of obstructive sleep apnea. Screening patients with lung cancer for obstructive sleep apnea is important regardless of the presence of classical symptoms of obstructive sleep apnea.

Orthorexia nervosa in dietitians and dietetics students-prevalence, risk factors, and interventions: a scoping review using a systematic approach.

CONTEXT: Orthorexia nervosa (ON) is characterized by compulsive behaviors and increased concerns about healthful eating. Dietitians appear to be especially vulnerable to ON, and it is still debatable whether the disordered eating behaviors motivate individuals to enroll in nutrition programs, or whether these behaviors result from an exaggerated preoccupation with healthy eating triggered during their nutrition studies. OBJECTIVE: The aim was to provide an overview of the present state of knowledge about the prevalence, risk factors, and interventions addressing ON among dietitians and dietetics students. More specifically, it was examined whether dietitians and dietetics students differ from students attending different education programs or other health professionals with regard to the severity and risk factors of ON, and whether the extent of ON changes during the progression in the nutrition education years of study. DATA SOURCES: MEDLINE (Ovid), PubMed, EMBASE (Ovid), PsycInfo (EBSCO), CINAHL (EBSCO), Cochrane, ProQuest Central, CABI, ProQuest Dissertations, Google Scholar, ScienceDirect, and SpringerLink were searched on May 8, 2021, and updated on November 12, 2022. DATA EXTRACTION: Records were screened for eligibility; study characteristics, methodology, and findings of included articles were extracted; and the methodological quality assessed using the AXIS tool. Each step was preceded by a calibration exercise and conducted independently and in duplicate by pairs of 2 reviewers. Any disagreements were resolved through discussions. DATA ANALYSIS: A narrative synthesis was performed, whereby the characteristics, methodologies, and results of included studies were compared. CONCLUSIONS: Results were inconclusive; yet, a general status of the relatively "high" prevalence of ON among dietitians and dietetics students was established, stressing the need for systematic research to understand and mitigate orthorexic tendencies in this group. It is still too early to answer questions pertaining to prevalence, risk factors, interventions, and differences between dietetics students and other majors when it comes to severity and progress of ON throughout the continuing years of study, or between dietitians and other professional groups. SYSTEMATIC REVIEW REGISTRATION: Open Science Framework Identifier: DOI 10.17605/OSF.IO/BY5KF.

Therapeutic targeting of cellular senescence in diabetic macular edema: preclinical and phase 1 trial results.

Compromised vascular endothelial barrier function is a salient feature of diabetic complications such as sight-threatening diabetic macular edema (DME). Current standards of care for DME manage aspects of the disease, but require frequent intravitreal administration and are poorly effective in large subsets of patients. Here we provide evidence that an elevated burden of senescent cells in the retina triggers cardinal features of DME pathology and conduct an initial test of senolytic therapy in patients with DME. In cell culture models, sustained hyperglycemia provoked cellular senescence in subsets of vascular endothelial cells displaying perturbed transendothelial junctions associated with poor barrier function and leading to micro-inflammation. Pharmacological elimination of senescent cells in a mouse model of DME reduces diabetes-induced retinal vascular leakage and preserves retinal function. We then conducted a phase 1 single ascending dose safety study of UBX1325 (foselutoclax), a senolytic small-molecule inhibitor of BCL-xL, in patients with advanced DME for whom anti-vascular endothelial growth factor therapy was no longer considered beneficial. The primary objective of assessment of safety and tolerability of UBX1325 was achieved. Collectively, our data suggest that therapeutic targeting of senescent cells in the diabetic retina with a BCL-xL inhibitor may provide a long-lasting, disease-modifying intervention for DME. This hypothesis will need to be verified in larger clinical trials. ClinicalTrials.gov identifier: NCT04537884 .

Developing the Lebanese health economic evaluation guideline.

OBJECTIVE: To report on the process of developing the Lebanese Economic Evaluation Guideline (LEEG), and to provide relevant material that could assist guideline developers in the future. METHODS: The development of the LEEG closely followed the process proposed by the World Health Organization, i.e. to set up a Guideline Development Group (composed of three Lebanese experts), to establish the rationale for developing the guideline in Lebanon, to identify its scope, to search and retrieve evidence through two systematic reviews, to assess and present the evidence, to translate the evidence into guidelines and recommendations through a deliberative process, and to consult international experts. The deliberative process included a survey, an in-person interview, and a consensus workshop with 16 Lebanese key stakeholders. Data was collected and quantitative analysis was conducted using SPSS software. International experts from Maastricht University - The Netherlands were consulted for issuing the LEEG. Supported by the Lebanese Ministry of Public Health (MoPH), the LEEG will be available for public consultation on the MoPH's webpage, and a final version will be made available thereafter. CONCLUSION: Clear and transparent reporting of the guideline development process should support international organizations as well as other developers in establishing their guidelines within their national context.

Abdominal volume index, waist-to-height ratio, and waist circumference are optimal predictors of cardiometabolic abnormalities in a sample of Lebanese adults: A cross-sectional study.

The prevalence of cardiometabolic abnormalities is high globally. This is concerning since these abnormalities increase the risk of morbidity and mortality. Using noninvasive, low-cost, and ethnic-specific anthropometric indices is crucial for widespread screening and early detection of cardiometabolic abnormalities. In this cross-sectional study, we enrolled 221 Lebanese participants (62.9% females; mean age: 43.36 ± 16.05 years; mean body mass index (BMI): 28.43 ± 6.10 Kg/m2). The main outcome measure was cardiometabolic abnormality (CMA), defined as the presence of at least two or more non-anthropometric components of the Metabolic Syndrome. Several anthropometric indices: Total body fat percent, Conicity index, Abdominal volume index (AVI), Weight-adjusted-waist index, Waist circumference (WC), Neck circumference, Hip circumference, Waist-to-hip ratio, Waist-to-height ratio (WtHR), Neck-to-height ratio, and BMI were assessed in their prediction of CMA, using logistic regression modelling and c-statistic [95% confidence intervals (CIs)], and calibration plots, as well sensitivity, specificity, and negative and positive predictive values measures. The Benjamini-Hochberg correction procedure was used to correct for multiple testing. The prevalence of CMA was 52.0% (47.5% in females and 59.8% in males). Significant associations were found between all the anthropometric indices and CMA, except for neck-to-height ratio. AVI and WC were most predictive for CMA in the total sample. WtHR and WC were most predictive in females with suggested cut-off values of 0.58 and 91.25 cm, whereas AVI and WC were most predictive in males with suggested cut-off values of 19.61 and 101.50 cm. The neck-to-height measurement had the lowest predictive ability for CMA. Adding anthropometric indices to sociodemographic variables did not significantly improve model discrimination. AVI, WHtR, and WC best predicted CMA in a sample of Lebanese adults. These less invasive, low-cost, easy-to-measure indices can be used to screen widely for CMA to better manage and prevent disease and subsequent morbidity and mortality.

Assessing the relationship between food insecurity and lifestyle behaviors among university students: a comparative study between Lebanon and Germany.

BACKGROUND: Food insecurity is a common public health problem in both developed and developing countries. This study aimed to profile food insecurity among university students in a developed country with stable economic circumstances (Germany) and a developing Mediterranean country undergoing a severe economic and financial crisis (Lebanon) and examine the associations between food insecurity and lifestyle behaviors (i.e., physical activity, sleep, and adherence to a healthy eating pattern, such as the Mediterranean diet), stress, and financial well-being. METHOD: This online cross-sectional study was conducted between September 2021 and March 2022. Subjects were recruited through social media platforms (Facebook, WhatsApp, Instagram, and personal email) and in-class announcements by several university professors of various majors and from different universities in Lebanon and Germany. The final sample included 547 participants (197 from Lebanon and 350 from Germany). RESULTS: Our findings showed a higher food insecurity rate in Lebanon compared with Germany (59% versus 33%). In the bivariate analysis, food insecurity was associated with insomnia (r = 0.230; p < 0.001) and stress (r = 0.225; p = 0.001); German university students had higher physical activity (p < 0.001), better diet quality (p < 0.001), and lower adherence to the Mediterranean diet (p < 0001) than Lebanese students. In the multivariable analyses, more stress was related to insomnia (B = 0.178; p < 0.001), while financial well-being was not associated with any of the lifestyle behaviors. Physical activity, insomnia, and Mediterranean diet adherence were not associated with the country or food insecurity (p > 0.05); however, living in Germany was associated with better diet quality (B = -7.85; p < 0.001). CONCLUSION: The high prevalence of food insecurity reported in this study is alarming, particularly among Lebanese students; German students had better diet quality and higher physical activity but worse adherence to the Mediterranean diet. Moreover, food insecurity was also associated with worse sleep and stress. Further studies are necessary to assess the role of food insecurity as a mediating factor between sociodemographic characteristics and lifestyle behaviors.

Association between Serum Vitamin D and Metabolic Syndrome in a Sample of Adults in Lebanon.

The evidence on the association between vitamin D and metabolic syndrome (MetS) is inconclusive. This was a cross-sectional study to explore the relationship between vitamin D serum levels and MetS in a sample of Lebanese adults (n = 230), free of diseases that affect vitamin D metabolism, recruited from an urban large university and neighboring community. MetS was diagnosed according to the International Diabetes Federation criteria. A logistic regression analysis was performed taking MetS as the dependent variable, and vitamin D was forced into the model as an independent variable. The covariates included sociodemographic, dietary, and lifestyle variables. The mean (SD) serum vitamin D was 17.53 (12.40) ng/mL, and the prevalence of MetS was 44.3%. Serum vitamin D was not associated with MetS (OR = 0.99 (95% CI: 0.96, 1.02), p < 0.757), whereas the male sex, compared with the female sex and older age, was associated with higher odds of having MetS (OR = 5.92 (95% CI: 2.44, 14.33), p < 0.001 and OR = 1.08 (95% CI: 1.04, 1.11), p < 0.001, respectively). This result adds to the controversy in this field. Future interventional studies are warranted to better understand the relationship between vitamin D and MetS and metabolic abnormalities.

The societal costs of multiple sclerosis in Lebanon: a cross-sectional study.

INTRODUCTION: This study assessed the societal costs of multiple sclerosis (MS) in Lebanon, categorized by disease severity. METHODS: This was a cross-sectional, prevalence-based, bottom-up study using a face-to-face questionnaire. Patients were stratified by disease severity using the expanded disability status scale (EDSS); EDSS scores of 0-3, 4-6.5, and 7-9 indicating respectively mild, moderate, and severe MS. All direct medical, nonmedical, and indirect costs related to reduced productivity were accounted for regardless of who bore them. Costs, collected from various sources, were presented in international US dollars (US$) using the purchasing power parity (PPP) conversion rate. RESULTS: We included 210 Lebanese patients (mean age: 43.3 years; 65.7% females). The total annual costs per patient were PPP US$ 33,117 for 2021, 12.4 times higher than the nominal GDP per capita. Direct costs represented 52% (US$ 17,185), direct nonmedical costs 8% (US$ 2,722), and indirect costs 40% (US$ 13, 211) of the mean annual costs. The total annual costs per patient increased with disease severity and were PPP US$ 29,979, PPP US$ 36,125, PPP US$ 39,136 for mild, moderate, and severe MS, respectively. CONCLUSION: This study reveals the huge economic burden of MS on the Lebanese healthcare system and society.

Patterns and Determinants of Weight Gain among People Who Use Drugs Undergoing Treatment for Recovery in Lebanon.

Substance use disorder compromises the nutritional status and the eating habits of drug users, often leading to malnutrition. Once referred for treatment, hyperphagia and poor lifestyle practices leading to weight gain are observed. This study aimed to examine the patterns and extent of weight change as well as the determinants of weight gain in a sample of drug users who were receiving treatment in Lebanon. A total of 172 male participants undergoing either rehabilitation or opioid substitution treatment (OST) were included. Multivariate regression analysis was applied to assess the effect of different variables on weight gain while adjusting for potentially confounding variables. Approximately two-thirds (65.1%) of the participants gained weight (OST: 54.3%, rehabilitation: 78.2%; p < 0.05). The mean weight gain was 5.9 kg and was mainly reported among participants in the underweight, normal, and overweight pre-treatment categories and accentuated in the rehabilitation group (OST: 2 kg, Rehabilitation: 10.6 kg). Around half of the participants moved from the normal weight category to the overweight and obese categories during treatment. Weight gain was negatively associated with the number of previous treatment attempts (Odds Ratio = 0.86; Confidence Interval: 0.74-0.99), duration of current treatment (Odds Ratio = 0.98; Confidence Interval: 0.96-0.99), and pre-treatment body mass index (BMI) (Odds Ratio = 0.88; Confidence Interval: 0.80-0.96). Investigating other nutrition and lifestyle practices, neither nutrition knowledge, food addiction, physical activity level, nor sleep quality were associated with weight gain. Treatment through drug use was associated with meaningful weight gain that might lead to health risk factors. Developing health promotion programs is crucial to enhance treatment and decrease the risk of relapse.

Prevalence of medication administration errors in hospitalized adults: A systematic review and meta-analysis up to 2017 to explore sources of heterogeneity.

Previous estimates to meta-analyze administration error rates were limited by the high statistical heterogeneity, restricting their use. This study aimed to investigate sources of heterogeneity in pooled administration error rates in hospitalized adults. We systematically searched scientific databases up to November 2017 for studies presenting error rates/relevant numerical data in hospitalized adults. We conducted separate meta-analyses for the numerators: One Medication Error (OME) (each dose can be correct or incorrect) and Total Number of Errors (TNE) (more than one error per dose could be counted), using the generic inverse variance with a 95% confidence interval. Heterogeneity was assessed using the I2 and Cochran's Q test. We meta-analyzed 33 studies. The global pooled analyses based on the OME and TNE numerators showed very high heterogeneity (I2  = 100%; p < 0.00001). For each meta-analysis, subgroup analyses based on study characteristics (countries, wards, population, routes of administration, error detection methods, and medications) yielded results with consistently elevated heterogeneity. Beyond these characteristics, we stratified the studies according to the mean error prevalence level as the threshold. Based on the OME numerator, we identified two subgroups of low (0.15[0.13-0.17]; I2  = 0%; p = 0.43) and high (0.26[0.24-0.27]; I2  = 38%; p = 0.17) pooled prevalence rates, with controlled heterogeneity. Similarly, for the TNE numerator, we identified two subgroups of low (0.10[0.09-0.10]; I2  = 0%; p = 0.76) and high (0.28[0.27-0.29]; I2  = 0%; p = 0.89) pooled prevalence rates, with controlled heterogeneity. These subgroups differed regarding the denominators used: Total opportunities for errors versus others (doses, observations, administrations). Calculation methods, specifically the denominator, seem a primary factor in explaining heterogeneity in error rates. Standardizing numerators, denominators, and definitions is necessary.

The psychological impact of COVID-19 in a socio-politically unstable environment: protective effects of sleep and gratitude in Lebanese adults.

BACKGROUND: The COVID-19 global pandemic initiated an unprecedented medico-psychological turmoil. Our study investigates the psychological impact of the viral spread and austere lockdown, and focuses mostly on potential protective factors in a politically and economically unstable society. METHODS: A cross-sectional design was used to evaluate rates of mental distress in a sample of 348 Lebanese adults. Participants filled questionnaires of perceived stress (PSS), depression (PHQ-9), anxiety (GAD-7), PTSD (IES-22), as well as sleep (PSQi) and gratitude (GQ-6) immediately after 3 months of strict quarantine. Demographics included gender, age, employment and infection statuses. Correlations and regression models were used. RESULTS: Results indicated a very high prevalence of mental distress, in addition to major alterations in sleep quality and quantity. Younger age and unemployment correlated with more severe symptoms. Sleep was found to be a protective factor against all studied psychological distress, and gratitude further mitigated effects of depression. CONCLUSIONS: Mental health significantly degrades post-COVID lockdown, even in the absence of direct viral threat. Yet simple behavioral and cognitive changes like sleep and attitude of gratitude could provide protective factors against these psychological distresses. Such changes should be further explored and advocated as cost-efficient self-care practices to buffer this devastating public health burden, especially in unstable socio-political environments.

Valuation of Costs in Health Economics During Financial and Economic Crises: A Case Study from Lebanon.

In 2019, we embarked on a study on the economic burden of multiple sclerosis (MS) in Lebanon, in collaboration with a premier Lebanese MS center. This coincided with a triple disaster in Lebanon, comprising the drastic economic and financial crisis, the COVID-19 pandemic, and the consequences of the explosion of Beirut's port. Specifically, the economic and financial turmoil made the valuation of costs challenging. Researchers could face similar challenges, particularly in low- and middle-income countries (LMICs) where economic crises and recessions are recurrent phenomena. This paper aims to discuss steps taken to overcome the fluctuation of the prices of resources to get a valid valuation of societal costs during times of a financial and economic crisis. In the absence of local costing data and guidelines for conducting cost-of-illness (COI) studies, this paper provides empirical recommendations on the valuation of costs that are particularly relevant in LMICs. We recommend (1) clear reporting and justification of the country-specific context, year of costing, assumptions, data sources, and valuation methods, as well as the indicators used to adjust cost for inflation during different periods of fluctuation of prices; (2) collecting prices of each resource from multiple and various sources; (3) conducting a sensitivity analysis; and (4) reporting costs in local currency and Purchasing Power Parity dollars (PPP$). Precision and transparency in reporting prices of resources and their sources are markers of the reliability of the COI studies.

Association between the bi-dimensional aspect of orthorexia and healthy behaviors among lebanese adolescents.

BACKGROUND: Recently, there has been a blooming focus on "eating healthy and clean", with the ideal of being healthy becoming a popular lifestyle trend. Previous research suggested the presence of two forms of orthorexia: Orthorexia Nervosa (OrNe) and Healthy Orthorexia (HeOr). Taking into consideration that orthorexia thoughts are led by the desire to reach an optimal physical health, the dedication to a healthy living may require healthy lifestyle habits: smoking cessation, moderate alcohol intake, and increased physical activity. The main study aim was to determine, among Lebanese adolescents, the association between healthy behaviors and the two likely forms of orthorexia (OrNe and HeOr), given that the adolescent phase is a risky period in the development of eating disorders. METHODS: A cross-sectional study, conducted between January and April 2022, enrolled 444 adolescents aged between 14 and 18 years, with an equitable random sample from all the Lebanese governorates (mean age 16.23 ± 1.15 years; 60.1% females). The Teruel Orthorexia Scale (TOS) was used to assess orthorexic eating tendencies. The Lebanese Waterpipe Dependence Scale, the Fagerström Test for Nicotine Dependence and the Alcohol Use Disorder Identification Test scales, all validated in adolescents, were used to evaluate the association between orthorexia and healthy behaviors. RESULTS: Higher TOS OrNe scores were significantly and highly correlated with the TOS HeOr scores (r = 0.68; p < 0.001). In the bivariate analysis, waterpipe smoking was weakly but significantly associated with more OrNe, whereas more physical activity was significantly and moderately associated with more HeOr. After adjusting over all sociodemographic characteristics, other behaviors and the other dimension of orthorexia, more alcohol use disorder was significantly but strongly associated with higher OrNe, whereas more physical activity remained significantly associated with higher HeOr. CONCLUSION: In light of our results, OrNe and HeOr might be considered as different entities, mainly in their associations with alcohol consumption and physical activity. This supports the hypothesis of OrNe being a new form of eating disorder, whereas HeOr possibly showing protective characteristics. Orthorexia is still a topic of controversy, especially in the probable presence of two facets that are still difficult to differentiate.

Association between Serum Vitamin D and Irritable Bowel Syndrome Symptoms in a Sample of Adults.

Vitamin D may be associated with irritable bowel syndrome (IBS) pathways. This cross-sectional study evaluated the associations between serum Vitamin D and IBS symptoms in a sample of Lebanese adults. Participants (n = 230; mean (SD) age: 43.36 (16.05) years, 62.9% females) were adults, free of diseases affecting Vitamin D metabolism, and recruited from a large university and the surrounding community. Serum Vitamin D (25-hydroxyvitamin D) was assessed using an automated chemiluminescence micro-particle immunoassay kit. The Birmingham IBS Symptom Questionnaire total scale, and pain, constipation, and diarrhea subscales were used to study IBS symptoms. Four linear regression analyses were performed, taking respectively the total scale and each of the subscales as the dependent variable. Vitamin D was forced into each model. Covariates included sociodemographic and medical variables, fluid intake, physical activity, sleep quality, stress, and adherence to the Mediterranean diet. Mean (SD) serum Vitamin D was 17.53 (12.40) ng/mL and mean (SD) Birmingham IBS Symptom Questionnaire was 16.98 (15.16) (pain: 20.75 (23.63), constipation: 25.06 (29.99), diarrhea: 9.88 (13.37)). Serum Vitamin D was not associated with the total score, nor with any of the subscales (p > 0.05 for the four regression analyses). Serum Vitamin D was not associated with IBS symptoms in a sample of Lebanese adults, adding to the controversy in this field. Further understanding of the pathophysiological mechanisms involved in Vitamin D and IBS is warranted.

The development process of economic evaluation guidelines in low- and middle-income countries: a systematic review.

OBJECTIVES: To review the development of economic evaluation guidelines (EEGs) in low- and middle-income countries (LMICs), with the goal of assisting those developing EEGs in LMICs. METHODS: We conducted a systematic search in MEDLINE (Ovid), PubMed, EconLit, Embase (Ovid), the Cochrane Library, and the gray literature until March 2021. We extracted data on the methods used in the EEG development process, the responsible party engaged, and the development team's composition. We conducted a quality assessment, using the Appraisal of Guidelines for Research and Evaluation-Health Systems tool, and then carried out a relative comparison. RESULTS: Fourteen EEGs and nine studies were identified. In ten countries, the Ministry of Health was responsible for handling the development process. The majority of LMICs who developed EEGs did not explicitly report the discipline of those involved in the process. The developers of EEGs followed four main steps: conducting a review on national guidelines, organizing workshops, and getting support from international experts or from organizations. One-third of the identified EEGs failed to engage multisectoral or multidisciplinary developers, and approximately 14 percent did not follow or report any recommended step. CONCLUSIONS: This study identified a scarcity of published information related to the development process and the suboptimal quality of included studies. It provides relevant material to support international organizations and developers of guidelines in LMICs in developing EEGs that fit their national context. In addition, this paper recommends a transparent approach to the design of guidelines and to reporting on the methods for developing them.

The Economic and societal burden of multiple sclerosis on lebanese society: a cost-of-illness and quality of life study protocol.

This protocol describes the estimation of the societal costs and quality-of-life (QOL) burden of multiple sclerosis (MS) in Lebanon. This cross-sectional, prevalence-based burden-of-illness study was carried out in a premier MS center in Lebanon. We enrolled Lebanese patients aged 18 years and older who had been diagnosed with MS more than 6 months. The study uses a bottom-up approach to estimate the cost-of-illness (COI) and QOL using a retrospective face-to-face interview questionnaire. This resource utilization questionnaire was adapted to the Lebanese context by clinical and health economics experts. The methodologies used to estimate the consumption of healthcare resources, informal care, and productivity losses are well-defined and aligned with the Lebanese healthcare system. Costs are presented overall and by MS severity levels. QOL is measured using the EuroQOL (EQ-5D-5 L) and Multiple Sclerosis International Quality of Life (MusiQoL) instrument. This protocol pioneers in informing the design of future COI and QOL studies in low - and middle-income countries (LMICs), as the methods used could be applied in similar LMICs. Furthermore, we provide recommendations and discuss the challenges of conducting a high-quality burden-of-illness study in LMICs and the steps taken to meet them, using the case of Lebanon.

Economic evaluation guidelines in low- and middle-income countries: a systematic review.

OBJECTIVES: To systematically identify the latest versions of official economic evaluation guidelines (EEGs) in low- and middle-income countries (LMICs) and explore similarities and differences in their content. METHODS: We conducted a systematic search in MEDLINE (Ovid), PubMed, EconLit, Embase (Ovid), the Cochrane Library, and the gray literature. Using a predefined checklist, we extracted the key features of economic evaluation and the general characteristics of EEGs. We conducted a comparative analysis, including a summary of similarities and differences across EEGs. RESULTS: Thirteen EEGs were identified, three pertaining to lower-middle-income countries (Bhutan, Egypt, and Indonesia), nine to upper-middle-income countries (Brazil, China, Colombia, Cuba, Malaysia, Mexico, Russian Federation, South Africa, and Thailand), in addition to Mercosur, and none to low-income countries. The majority (n = 12) considered cost-utility analysis and health-related quality-of-life outcome. Half of the EEGs recommended the societal perspective, whereas the other half recommended the healthcare perspective. Equity considerations were required in ten EEGs. Most EEGs (n = 11) required the incremental cost-effectiveness ratio and recommended sensitivity analysis, as well as the presentation of a budget impact analysis (n = 10). Seven of the identified EEGs were mandatory for pharmacoeconomics submission. Methodological gaps, contradictions, and heterogeneity in terminologies used were identified within the guidelines. CONCLUSION: As the importance of health technology assessment is increasing in LMICs, this systematic review could help researchers explore key aspects of existing EEGs in LMICs and explore differences among them. It could also support international organizations in guiding LMICs to develop their own EEGs and improve the methodological framework of existing ones.

Economic Burden of Multiple Sclerosis in Low- and Middle-Income Countries: A Systematic Review.

BACKGROUND: Although the economic burden of multiple sclerosis (MS) in high-income countries (HICs) has been extensively studied, information on the costs of MS in low- and middle-income countries (LMICs) remains scarce. Moreover, no review synthesizing and assessing the costs of MS in LMICs has yet been undertaken. OBJECTIVE: Our objective was to systematically identify and review the cost of illness (COI) of MS in LMICs to critically appraise the methodologies used, compare cost estimates across countries and by level of disease severity, and examine cost drivers. METHODS: We conducted a systematic literature search for original studies in English, French, and Dutch containing prevalence or incidence-based cost data of MS in LMICs. The search was conducted in MEDLINE (Ovid), PubMed, Embase (Ovid), Cochrane Library, National Health Service Economic Evaluation Database (NHS EED), Econlit, and CINAHL (EBSCO) on July 2020 without restrictions on publication date. Recommended and validated methods were used for data extraction and analysis to make the results of the COI studies comparable. Costs were adjusted to $US, year 2019 values, using the World Bank purchasing power parity and inflated using the consumer price index. RESULTS: A total of 14 studies were identified, all of which were conducted in upper-middle-income economies. Eight studies used a bottom-up approach for costing, and six used a top-down approach. Four studies used a societal perspective. The total annual cost per patient ranged between $US463 and 58,616. Costs varied across studies and countries, mainly because of differences regarding the inclusion of costs of disease-modifying therapies (DMTs), the range of cost items included, the methodological choices such as approaches used to estimate healthcare resource consumption, and the inclusion of informal care and productivity losses. Characteristics and methodologies of the included studies varied considerably, especially regarding the perspective adopted, cost data specification, and reporting of costs per severity levels. The total costs increased with greater disease severity. The cost ratios between different levels of MS severity within studies were relatively stable; costs were around 1-1.5 times higher for moderate versus mild MS and about two times higher for severe versus mild MS. MS drug costs were the main cost driver for less severe MS, whereas the proportion of direct non-medical costs and indirect costs increased with greater disease severity. CONCLUSION: MS places a huge economic burden on healthcare systems and societies in LMICs. Methodological differences and substantial variations in terms of absolute costs were found between studies, which made comparison of studies challenging. However, the cost ratios across different levels of MS severity were similar, making comparisons between studies by disease severity feasible. Cost drivers were mainly DMTs and relapse treatments, and this was consistent across studies. Yet, the distribution of cost components varied with disease severity.