Efficacy of opioid-free anesthesia in modified radical mastectomy: a cross-sectional observational study.

Introduction: Perioperative management of female patients undergoing breast surgeries differs from other patients due to chronic pain and postoperative nausea and vomiting. The anesthesia could consist of opioid-free general anesthesia (OFA) or non-opioid-free general anesthesia (NOFA). OFA relies on multimodal analgesia preoperatively and postoperatively. However, it is not yet established whether OFA could replace NOFA as a standard regimen for the management of breast surgeries. The aim of this study is to evaluate the efficacy of OFA for breast surgeries in female patients. Materials and methods: Patients undergoing modified radical mastectomy were retrospectively recruited. Two groups were defined: group 1, consisting of treated patients using OFA and group 2, consisting of treated patients using NOFA. Mean time to extubate and mean dose of morphine after recovery were computed. Postoperative morphine and antiemetic use were assessed for up to 24 h. A comparison of the computed data was conducted between both groups. Results: A total of 116 patients were included with a mean age of 53±13 years. Group 1 consisted of 56 (mean age was 54±14 years). Group 2 consisted of 60 patients (mean age was 51±12 years). Demographic parameters and time to extubate did not yield significant differences. We noticed morphine sparing at T0 and T12 with statistically significant differences P=0.043 and P=0.006, respectively. Conclusion: OFA could be considered in modified radical mastectomy management in female patients; nerve block seemed to act as morphine sparing in operative and postoperative settings by providing significantly less time to extubate with less postoperative morphine requirement.

Zuclopenthixol Induced Ischemic Priapism: Case Report and Review of Literature.

Objective: Present a case of zuclopenthixol associated priapism, literature review and focus on the stuttering priapism entity as a potential serious complication as well as providing information about possible preventive treatments. Case report: A 44 year-old male patient with history of cocaine abuse with associated priapism presents with acute painful erection after starting zuclopenthixol for treatment of a psychotic episode. This episode was later followed by many other similar episodes defined as stuttering priapism. Conclusion: Acute ischemic priapism is a potential serious side effect of antipsychotics that physicians especially psychiatrists needs to be aware of especially if the patient has previous episodes in order to prevent reoccurrence.

The effect of polypharmacy on healthcare services utilization in older adults with comorbidities: a retrospective cohort study.

BACKGROUND: Older adults are more prone to increasing comorbidities and polypharmacy. Polypharmacy is associated with inappropriate prescribing and an increased risk of adverse effects. This study examined the effect of polypharmacy in older adults on healthcare services utilization (HSU). It also explored the impact of different drug classes of polypharmacy including psychotropic, antihypertensive, and antidiabetic polypharmacy on HSU. METHODS: This is a retrospective cohort study. Community-dwelling older adults aged ≥ 65 years were selected from the primary care patient cohort database of the ambulatory clinics of the Department of Family Medicine at the American University of Beirut Medical Center. Concomitant use of 5 or more prescription medications was considered polypharmacy. Demographics, Charlson Comorbidity index (CCI), and HSU outcomes, including the rate of all-cause emergency department (ED) visits, rate of all-cause hospitalization, rate of ED visits for pneumonia, rate of hospitalization for pneumonia, and mortality were collected. Binomial logistic regression models were used to predict the rates of HSU outcomes. RESULTS: A total of 496 patients were analyzed. Comorbidities were present in all patients, with 22.8% (113) of patients having mild to moderate comorbidity and 77.2% (383) of patients having severe comorbidity. Patients with polypharmacy were more likely to have severe comorbidity compared to patients with no polypharmacy (72.3% vs. 27.7%, p = 0.001). Patients with polypharmacy were more likely to visit the ED for all causes as compared to patients without polypharmacy (40.6% vs. 31.4%, p = 0.05), and had a significantly higher rate of all-cause hospitalization (adjusted odds ratio aOR 1.66, 95 CI = 1.08-2.56, p = 0.022). Patients with psychotropic polypharmacy were more likely to be hospitalized due to pneumonia (crude odds ratio cOR 2.37, 95 CI = 1.03-5.46, p = 0.043), and to visit ED for Pneumonia (cOR 2.31, 95 CI = 1.00-5.31, p = 0.049). The association lost significance after adjustment. CONCLUSIONS: The increasing prevalence of polypharmacy amongst the geriatric population with comorbidity is associated with an increase in HSU outcomes. As such, frequent medication revisions in a holistic, multi-disciplinary approach are needed.

Sleep pattern and predictors of daily versus as-needed hypnotics use in middle-aged and older adults with insomnia.

INTRODUCTION: This study aims to examine the sleep pattern and predictors of daily vs. as-needed use of hypnotics in middle-aged and older adults with insomnia. METHODS: Patients aged 50-75 who use hypnotics for insomnia were identified via electronic medical records and were recruited. Data about sociodemographics, mood and cognitive screening measures, and questions related to sleep patterns were collected through an interview conducted over the phone. RESULTS: A sample of 66 participants was recruited, of which 69.7% were females. Three quarters (49/66, 74.2%) used hypnotics daily, with 43% (21/49) of daily hypnotics users sleeping more than 8 h per night. Two-fifths (26/66, 39.4%) of participants still had clinically significant insomnia even after taking hypnotics. After adjusting for age, years of hypnotics use, sleeping hours per night, PHQ-2 score, and frequency of pain at night, the logistic regression model showed that younger age (p = 0.023) and longer sleeping hours per night (p = 0.025) were significantly associated with daily hypnotics use when compared to as needed hypnotics use. CONCLUSION: Many hypnotic users still have clinically significant insomnia and poor quality of sleep as reflected by perceived longer sleep duration and more daytime napping which could be related to drug-related residual sedation. Hypnotic use may not be the best solution for insomnia treatment in an older population, and physicians should regularly reassess the use of hypnotics.

Impact of a Multifaceted Intervention Among Primary Care Physicians on Sickness Certification.

INTRODUCTION: Sickness absence remains a major challenge globally. Primary care physicians often find it challenging to deny patients' requests for sick leaves, making the gatekeeping role uneasy among doctors. METHODS: Twenty-one PCPs participated in this non-randomized intervention study. The educational intervention consisted of an interactive presentation, a 20-minute video screening, and 3 text message reminders. The average number for sickness certificates (SCs), sickness absence rate per patient, and causes for sickness absence spells were measured one year before and one year after the intervention. RESULTS: The average number of SC one year before and after the intervention was 0.44 and 0.47, respectively. The sickness absence rate was 0.63% one year before and 0.75% one year after the intervention with no statistical significance. The mean number of sickness absence days did not significantly change. Causes for sickness absence spells significantly increased for diarrhea and back pain but decreased for upper respiratory infections with no statistical significance. DISCUSSION: Implementation of a multifaceted intervention to train PCPs on the process of sickness certification did not affect the sickness absence rate. Further research is needed to assess the knowledge and understanding of physicians' sickness certification process and the underlying factors that govern it to better develop tailored and effective interventions.

Awareness and attitudes towards advance care planning in primary care: role of demographic, socioeconomic and religiosity factors in a cross-sectional Lebanese study.

OBJECTIVE: To assess awareness and attitudes towards engaging in advance care planning (ACP) and their relationship with demographic, socioeconomic and religiosity factors among Lebanese middle-aged to older-aged adults in primary care. DESIGN: A cross-sectional survey study. SETTING: Tertiary referral hospital in Beirut, Lebanon. PARTICIPANTS: A total of 215 middle-aged to older-aged adults. RESULTS: Out of 215 participants, 18.6% of participants knew about ACP; 94% favoured truth-telling; 87.4% favoured healthcare autonomy; 77.2% favoured documenting their own health values and preferences; and 29.3% were willing to undergo life-prolonging interventions. Among participants who were aware of ACP, 67.5% preferred ACP documentation and 85% had negative attitudes towards life-sustaining interventions. Women were more aware about ACP than men. Those who were willing to undergo life-prolonging interventions were found to be men and had higher religiosity scores. CONCLUSION: Large deficit in ACP awareness was evident despite the high preference for healthcare autonomy. Medical and public health efforts should strive to enhance patients' ACP awareness and engagement in ACP while considering factors relevant to gender, culture and religiosity.

Mild Cognitive Impairment and modifiable risk factors among Lebanese older adults in primary care.

OBJECTIVE: Mild Cognitive Impairment (MCI) is an intermediate state between normal cognition and dementia. Identification of MCI and associated risk factors is important for early intervention. This study investigated the prevalence of MCI among Lebanese older adults and associated risk factors in primary care. METHODS: For this cross-sectional study, 337 adults aged 60 years and older met inclusion criteria and were recruited at a primary care clinic associated with a tertiary medical center in Beirut, Lebanon. The validated Arabic version of the Montreal Cognitive Assessment, the 5-item Geriatric Depression Scale, and the Lawton Instrumental Activities of Daily Living Scale were administered. Data about sociodemographic, behavioral, and clinical characteristics was obtained. RESULTS: There was no difference in the mean age between those with normal cognition and those with MCI (mean age 70.38 ± 7.4 and 72.12 ± 7.6 years, respectively). The prevalence of MCI was 14.8% (50 out of 337), 42% were males and 58% were women. Participants having more than 12 years of education (OR = 0.297; CI = 0.112-0.788; P = 0.015) were less likely to have MCI. Participants with history of smoking (OR = 2.599; CI = 1.266-5.339; P = 0.012) or at risk of depression (OR = 2.847; CI = 1.392-5.819; P = 0.004) were more likely to have MCI. CONCLUSION: Identification of patients with history of smoking and at risk of depression may serve as an opportunity to offer intensive counseling and targeted treatment to delay the onset or progression of MCI to Alzheimer's disease.

A Novel Technique for the Treatment of a Case of Verneuil's Disease of Perineum and Axillary Regions.

Hidradenitis suppurativa (HS) is a chronic inflammatory disease involving apocrine glands of the skin. It carries out an important burden on the daily life of the patient. Unfortunately, it presents a major concern for medical care management in the absence of clear guidelines for proper medical and surgical treatment. Hence, we report a case of concomitant axillary and perianal HS. We opted for surgical management using a novel technique, which proved efficacy for a year of follow-up recurrence free.

Knowledge and attitude towards Alzheimer's disease and related dementias in a low- to middle-income country: a cross-sectional survey among Lebanese middle-aged and older adults.

BACKGROUND: Despite the growing burden of Alzheimer's disease and related dementias (ADRD) in low- to middle-income countries (LMICs) and prior findings of important gaps in research on ADRD knowledge, very few studies have assessed ADRD knowledge in these populations. This study evaluates the knowledge and attitudes towards ADRD among Lebanese middle-aged and older adults. METHOD: Participants aged ≥ 40 (n = 215) attending primary care clinics at a large medical centre in Lebanon completed the Alzheimer's Disease Knowledge Scale (ADKS), an attitude scale, and the Duke University Religion Index. RESULTS: ADRD knowledge accuracy was 61.5% (mean score = 18.6 out of 30 (SD = 3.05)). Items with the least correct answers were related to caregiving and risk factors (≤9% and ≤28%). Overall, participants had tolerant views concerning ADRD; the least positive views were regarding living with people with ADRD. Older age, lower educational attainment, and higher religiosity scores were associated with poorer knowledge and attitudes. CONCLUSION: Results highlight the need for awareness and preventive efforts that address misconceptions about modifiable risk factors and living with ADRD, especially given that the burden of caregiving for older adults often falls on family members in Lebanon and other LMIC countries.

Knowledge and attitude of primary care physicians towards obstructive sleep apnea in the Middle East and North Africa region.

BACKGROUND/OBJECTIVES: Sleep disorders are highly prevalent in primary care. Obstructive sleep apnea (OSA) is one of the most common sleep disorders in the world, and it is estimated that only 10 to 20% of OSA cases are diagnosed. Primary care physicians (PCP) play an important role in screening for OSA. Knowledge of sleep disorders among PCP varies widely and has been generally reported as low. In this study, we aimed to assess the knowledge and attitudes towards OSA among primary care physicians in the Middle East and North Africa regions. METHODS: A cross-sectional study using the Obstructive Sleep Apnea Knowledge and Attitudes (OSAKA) self-administered questionnaire was distributed to PCP attending the Lebanese Society of Family Medicine annual conference, the Lebanese Society of Internal Medicine annual conference, and World Organization of Family Doctors (WONCA) East Mediterranean region conference. RESULTS: Of 300 physicians approached, 256 (85%) completed the questionnaires. The range of possible scores was 0 to 18. The mean total knowledge score with standard deviation (SD) was 12.6 (2.5). Internal medicine specialists showed a higher mean knowledge score of 14.1 (2.3) compared to general/family medicine specialists 12.4 (2.4) and other specialties 11.9 (2.8), p = 0.001. Though 78% of all physicians felt confident in identifying patients with OSA, only 26% felt confident in managing patients with continuous positive airway pressure. Overall, there was a weak positive correlation between knowledge and attitude. CONCLUSION: There were gaps in knowledge and attitudes regarding managing patients with OSA. Training in managing patients with OSA is needed.

The Efficacy of Opioid-Free General Anesthesia in the Management of Hip Surgeries in Elderly Patients.

Introduction Perioperative management of elderly patients differ from young patients due to physiologic and pharmacologic differences related to aging. Moreover, assessment for perioperative parameters and risks between age-matched elderly patients should be discerned while planning for the anaesthesia regimen. The latter could consist of opioid-free general anaesthesia (OFA) or non-opioid-free general anaesthesia (NOFA). Among the parameters for assessing the regimen's efficacy, time to extubate and pain control should be included. However, it is not yet established whether OFA could replace NOFA as a standard regimen for management of hip fracture. Therefore, the aim of this study is to evaluate the efficacy of OFA for hip surgeries in elderly patients. Methods This is a retrospective study consisting of patients undergoing hip surgeries under opioid-free or opioid-induced general anaesthesia. Two groups were defined: Group 1 consisting of treated patients using OFA and Group 2 consisting of treated patients using NOFA. Patient demographics (age, sex, and weight), mean time to extubate and mean dose of morphine after recovery were computed. Postoperative morphine use was assessed for up to 24 hours. Comparison of the computed data was conducted between both groups. Mean postoperative morphine use was compared using the Mann-Whitney U-test. The remainder of the means were compared using independent t-test. Qualitative data were compared using Fisher's exact test. Level of significance was set at p<0.05. Results A total of 73 patients were included. Group 1 consisted of 37 patients (12 were males with mean age 77±14 years) who underwent hip fracture procedure whereas Group 2 consisted of 36 patients (18 were males with mean age 73±17). There were significant differences when comparing sex, weight, and time to extubate (6.8±3 and 10±5 minutes in Groups 1 and 2, respectively; p<0.05). There were six patients in Group 1 and 17 patients in Group 2 that required postoperative morphine administration. Mann-Whitney U comparison of postoperative morphine use yielded significant differences (4.8±3 and 14.65±13 mg in Groups 1 and 2, respectively; p=0.001). Discussion This is the first study that assessed the efficacy of OFA compared to NOFA in the management of hip fractures. Non-significant differences in age might suggest that both groups are age matched. In addition, significant differences in time to extubate might help in reducing impact on ventilation, maintaining safe anaesthesia while minimizing intraoperative work overflow. Patients in Group 1 required less morphine in the postoperative setting than in Group 2. This might be explained by the sensation of paraesthesia which might have been confused with pain. Conclusions OFA could be considered in hip management in elderly patients; femoral and lateral cutaneous block seemed to act as morphine sparing in operative and postoperative settings by providing significantly less time to extubate with less postoperative morphine requirement.

Management of patients with high-risk and advanced prostate cancer in the Middle East: resource-stratified consensus recommendations.

PURPOSE: Prostate cancer care in the Middle East is highly variable and access to specialist multidisciplinary management is limited. Academic tertiary referral centers offer cutting-edge diagnosis and treatment; however, in many parts of the region, patients are managed by non-specialists with limited resources. Due to many factors including lack of awareness and lack of prostate-specific antigen (PSA) screening, a high percentage of men present with locally advanced and metastatic prostate cancer at diagnosis. The aim of these recommendations is to assist clinicians in managing patients with different levels of access to diagnostic and treatment modalities. METHODS: The first Advanced Prostate Cancer Consensus Conference (APCCC) satellite meeting for the Middle East was held in Beirut, Lebanon, November 2017. During this meeting a consortium of urologists, medical oncologists, radiation oncologist and imaging specialists practicing in Lebanon, Syria, Iraq, Kuwait and Saudi Arabia voted on a selection of consensus questions. An additional workshop to formulate resource-stratified consensus recommendations was held in March 2019. RESULTS: Variations in practice based on available resources have been proposed to form resource-stratified recommendations for imaging at diagnosis, initial management of localized prostate cancer requiring therapy, treatment of castration-sensitive/naïve advanced prostate cancer and treatment of castration-resistant prostate cancer. CONCLUSION: This is the first regional consensus on prostate cancer management from the Middle East. The following recommendations will be useful to urologists and oncologists practicing in all areas with limited access to specialist multi-disciplinary teams, diagnostic modalities and treatment resources.

Mild cognitive impairment in primary care: a clinical review.

Dementia is projected to become a global health priority but often not diagnosed in its earlier preclinical stage which is mild cognitive impairment (MCI). MCI is generally referred as a transition state between normal cognition and Alzheimer's disease. Primary care physicians play an important role in its early diagnosis and identification of patients most likely to progress to Alzheimer's disease while offering evidenced-based interventions that may reverse or halt the progression to further cognitive impairment. The aim of this review is to introduce the concept of MCI in primary care through a case-based clinical review. We discuss the case of a patient with MCI and provide an evidence-based framework for assessment, early recognition and management of MCI while addressing associated risk factors, neuropsychiatric symptoms and prognosis.

Children born to mothers in their 20s and fathers in their 40s: Evidence for an increased low birth weight and Cesarean Section deliveries in Lebanon.

PURPOSE: Much less is known about the effect of advanced paternal age (APA) (≥40 years) than advanced maternal age on neonatal morbidity. More specifically, the correlation with low birth weight remains inconsistent. This study aims to determine whether APA among mothers aged 20-29 years is associated with a higher risk of low birth weight and other neonatal outcomes. METHODS: Data from 2004 to 2008 database of the National Collaborative Perinatal Neonatal Network were used. Fifteen thousand two hundred eighteen live birth singleton pregnancies by primigravida mothers aged 20-29 years were analyzed. Study variables include paternal age (years), C-section delivery (yes/no), low birth weight (<2500 g), and preterm births (<37 weeks of gestation). Regressions were generated controlling for birth defects, consanguinity, maternal education, prenatal care, gender, and maternal smoking. RESULTS: Adjusted odds of Low Birth Weight (LBW) and Cesarean Section Deliveries (CSD) were significantly higher in infants of APA fathers compared to those of fathers aged 30-35 years [adjusted odds ratio (95% confidence interval) = 1.5 (1.1, 2.3) and 1.4 (1.1, 1.7), respectively]. Paternal ages of 35-39 years compared to less than 30 years were associated with higher odds of CSD [adjusted odds ratio = 1.4 (1.2, 1.5)]. APA was not associated with preterm birth after adjustment. CONCLUSIONS: This study supports the association between APA and increased risk for LBW and CSD.

Medical students' knowledge, attitudes and behaviours related to substance use in Lebanon: a cross-sectional survey.

The study aims were to explore the knowledge, attitudes and behaviours of Lebanese medical students related to substance use and to determine prevalence and psychosocial predictors. A cross-sectional survey of 231 medical students (48.6% male; 53.1% preclinical, 46.9% clinical) was conducted during June 2012-July 2013. The questionnaire addressed knowledge and attitudes about substance use, religiosity, depression, anxiety and demographic characteristics. The knowledge score was 52.7% (standard deviation 14.4%), and was significantly lower in 2nd year students (48.53%) than in 3rd and 4th year students (57.5% and 57.4%) (P < 0.05). Students reported more training in drug abuse than alcohol abuse (38.2% vs. 34.4%). One-fourth reported smoking, 57.7% using alcohol and 46.8% using drugs. Significant predictors of lower substance use included intrinsic religiosity and interest in working in the field. The findings reveal inadequate knowledge and considerable substance use in Lebanese medical students. Therefore, training in substance use and counseling of students are necessary.