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BACKGROUND: Interprofessional collaboration is key to improving the health of individuals and communities. It is supported by provision of Interprofessional education (IPE) which has recently emerged in the Middle East region. This study investigated changes in healthcare students' attitudes towards interprofessional collaboration after undertaking the Interprofessional Education and Collaboration (IPEC) course. METHODS: A paper-based anonymous survey using the Interprofessional Attitude Scale (IPAS) was administered to a sample of 346 health students (nursing, medicine, and public health) pre/post undertaking the IPEC course. Less than half of the students provided a post response, with pre/post survey results of 111 pairs subsequently matched and analyzed. RESULTS: Results showed elevated pre-course scores, an improvement in students' attitudes towards the interprofessional biases domain of the IPAS, and a slight decline in their scores in the remaining 4 domains (team roles and responsibilities, patient centeredness, community centeredness, and diversity and ethics). These changes were not statistically significant, except for the patient centeredness domain (p = 0.003**). CONCLUSIONS: The study provided important results about attitudes towards interprofessional collaboration. These findings are essential because our institution is one of few in Lebanon that provides this mandatory course to a large group of health professionals. Future studies should investigate these changes in attitude scores in a larger sample size, and how these attitudes would influence collaboration post-graduation.
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Relaciones Interprofesionales , Estudiantes de Enfermería , Actitud del Personal de Salud , Conducta Cooperativa , Humanos , Educación Interprofesional , Líbano , EstudiantesRESUMEN
OBJECTIVES: Safety climates that support safety-related behaviour are associated with fewer work-related injuries, and prior research in industry suggests that safety knowledge and motivation are strongly related to safety performance behaviours; this relationship is not well studied in healthcare settings. METHODS: We performed analyses of survey results from a Veterans Health Administration (VHA) Safety Barometer employee perception survey, conducted among VHA employees in 2012. The employee perception survey assessed 6 safety programme categories, including management participation, supervisor participation, employee participation, safety support activities, safety support climate and organisational climate. We examined the relationship between safety climate from the survey results on VHA employee injury and illness rates. RESULTS: Among VHA facilities in the VA New England Healthcare System, work-related injury rate was significantly and inversely related to overall employee perception of safety climate, and all 6 safety programme categories, including employee perception of employee participation, management participation, organisational climate, supervisor participation, safety support activities and safety support climate. CONCLUSIONS: Positive employee perceptions of safety climate in VHA facilities are associated with lower work-related injury and illness rates. Employee perception of employee participation, management participation, organisational climate, supervisor participation, safety support activities and safety support climate were all associated with lower work-related injury rates. Future implications include fostering a robust safety climate for patients and healthcare workers to reduce healthcare worker injuries.
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Traumatismos Ocupacionales/epidemiología , Traumatismos Ocupacionales/prevención & control , Cultura Organizacional , Administración de la Seguridad , Conocimientos, Actitudes y Práctica en Salud , Humanos , Modelos Lineales , Salud Laboral , Administración de la Seguridad/organización & administración , Encuestas y Cuestionarios , Estados Unidos/epidemiología , United States Department of Veterans AffairsRESUMEN
BACKGROUND: Healthcare workers (HCWs) faced substantial risk of infection during the COVID-19 outbreak. This study aims to determine the prevalence of anti-SARS-CoV-2 antibodies in a cross-sectional sample of HCWs as well as risk factors associated with exposure to SARS-CoV-2. METHODS: The study was conducted between March and May 2021 at the American University of Beirut Medical Center (AUBMC), a tertiary hospital located in Lebanon. Socio-demographic and clinical data, as well as data on exposure, PCR results, PPE adherence, and vaccination status, were collected using an online questionnaire. Sera were also collected to determine seropositivity using commercially available enzyme-linked immunoassay (ELISA) targeting the spike (S) and the nucleocapsid proteins (NCP) of SARS-CoV-2. FINDINGS: Among 92 recruited HCWs, 72.3% received PPE training, more than 70% were adherent to using appropriate PPEs, and around 80% were vaccinated. Nurses in this study population were at higher risk of exposure compared to medical doctors, technicians, and other HCWs. Among the HCWs who performed a PCR test, 28.6% were infected with SARs-CoV-2 with workplace exposure not associated with COVID-19 infection. All vaccinated HCWs were seropositive for anti-S IgG with high titer (≥384 BAU/mL), with a significantly higher median anti-S IgG titer compared to unvaccinated HCWs with previous infection (384 vs. 140.1 BAU/mL; p = .0043). CONCLUSIONS: Our study highlights the importance of implementing strict infection control policies among HCWs and deploying an effective COVID-19 vaccination strategy. More studies are needed in Lebanon to assess risk factors of SARS-CoV-2 exposure in the workplace.
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COVID-19 , SARS-CoV-2 , Humanos , Líbano , Vacunas contra la COVID-19 , Estudios Transversales , Personal de Salud , Factores de Riesgo , Inmunoglobulina GRESUMEN
BACKGROUND: The COVID-19 pandemic strained healthcare systems around the world. This study aims to understand the preparedness of private remote hospitals in Lebanon to respond to the pandemic and evaluate the impact of inter-hospital collaborations on the hospitals' readiness. METHODS: A multi-centered study was conducted between August 2020 and June 2021 in ten Lebanese private remote hospitals based on a mixed-methods embedded approach where the quantitative supported the qualitative. Through the AUB-USAID (American University of Beirut-United States Agency for International Development) COVID-19 project, these hospitals received personal protective equipment and medical equipment in addition to COVID-19-related training using the Train-the-Trainer model. The quantitative part used knowledge and evaluation questionnaires and a pre-post-intervention hospital preparedness checklist. The qualitative approach adopted semi-structured interviews with a purposive sample from key hospital personnel. Quantitative data were analyzed using SPSS version 27, and a p-value of <0.05 was considered to be statistically significant. For the qualitative data, a thematic analysis was performed by adopting the six-phase process described by Braun and Clarke. RESULTS: Of the 393 healthcare workers who attended the training and completed the evaluation questionnaire, 326 completed the pre- and post-training knowledge questionnaire. A significant improvement was observed in mean knowledge scores following training for infection control, nursing, and polymerase chain reaction sampling staff (p-value < 0.001, p-value < 0.001, and p-value = 0.006, respectively), but not for housekeeping staff. More than 93% of the participants showed high trainer and content evaluation scores. As for the hospitals' preparedness assessments, there was a clear improvement in the pre- and post-assessment scores for each hospital, and there was a significant difference in the mean of the total scores of partner hospitals pre- and post-USAID-AUB project (p-value = 0.005). These findings were supported by the qualitative analysis, where nine hospitals expressed the positive impact of the USAID-AUB intervention in improving their preparedness to respond to the COVID-19 pandemic at a critical time when it was highly needed. Despite the intervention, persistent challenges remained. CONCLUSIONS: A timely and proactive collaborative program between academic/tertiary care centers and remote community hospitals that includes sharing supplies and expertise is feasible and highly effective during public health emergencies.
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The availability of and access to COVID-19 vaccines has been challenging in many low- and middle-income countries (LMICs), coupled with mistrust in public health organizations instigated by misinformation and disinformation diffused by traditional and social media. In the Spring of 2021, the American University of Beirut (AUB) in Lebanon spearheaded a nationwide vaccination drive with the ambitious goal of vaccinating its entire community by the beginning of the academic year 2021-2022, as the campus was due to be opened only to vaccinated individuals. This case study outlines the development, implementation, and evaluation of a social marketing campaign to encourage COVID-19 vaccinations among members of the AUB community, comprising students, faculty, staff, and dependents. Following French and Evans' 2020 guidelines, we implemented an evidence-based and co-designed strategy to maximize the availability and facilitate vaccine access. The campaign used a mix of methods to convince the segments of the population to receive their shots before accessing campus, resulting in a 98% uptake among the community segments within three months (July-September 2021). In this case study, we reflect on the experience and share suggestions for future research and applications that other higher education institutions could use to address similar problems.
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Background: Compared to the general workforce, hospital staff has a greater incidence of chronic diseases and mental health illnesses. Wellness programs have been shown to improve the health and well-being of hospital employees by reducing risk factors and promoting healthy behaviors. In the Arab World, there are no available studies on the number, nature, or impact of wellness services provided to healthcare workers. Objective: The study aims to assess the prevalence, characteristics, and components of health and wellness programs targeting hospital employees in Arab countries. It also aims to test the association of hospitals' characteristics and the challenges faced by these hospitals with the availability of such programs. Methods: A cross-sectional study was conducted through an online questionnaire in English and Arabic emailed to directors of Arab hospitals registered in the Arab Hospital Federation. Results: Only 39.5% of the hospitals in the Arab region have an established wellness program. No significant association was found between hospital characteristics and the availability of these wellness programs. The most provided services for hospital staff are Flu vaccine (90.7%), pre-employment medical exam (79.1%), healthy food options (65.1%), and health risk assessment (60.5%), while the least common provided services are mental health (20.9%) and stress management (23.3%). The most common challenges facing wellness services (scale: 0-10) are financial restriction (5.95), creating a culture of health (5.88), and motivating employees (5.56). Only 4.7% of hospitals provide incentives to participate in their wellness programs. Conclusion: In general, Arab hospitals lack a wellness culture, and more investment is needed in essential wellness services such as mental health, weight reduction, stress management, and smoking cessation.
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BACKGROUND: Little has been published on predictors of prolonged sick leaves during the COVID-19 pandemic. This study aims to determine the rate of COVID-19 infections among healthcare workers (HCWs) and to identify the predictors of longer sick leave days. METHODS: We identified predictors of longer sick leave using linear regression analysis in a cross-sectional study design. RESULTS: Thirty-three percent of the total workforce contracted COVID-19. On average, HCWs took 12.5 sick leave days after COVID-19 infection. The regression analysis revealed that older employees, nurses, and those who caught COVID-19 earlier in the pandemic were more likely to take longer sick leave. CONCLUSIONS: Age, job position, and month of infection predicted sick leave duration among HCWs in our sample. Results imply that transmission was most likely community-based. Public health interventions should consider these factors when planning for future pandemics.
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COVID-19 , Humanos , COVID-19/epidemiología , Pandemias , Centros de Atención Terciaria , Estudios Transversales , Personal de Salud , Ausencia por EnfermedadRESUMEN
Background: Healthcare workers (HCWs) have been severely impacted by the COVID-19 pandemic. In addition to their risk of direct exposure to the virus, they were subjected to long working hours, scarcity of PPE, and additional stressors that impacted their psychological wellbeing. The purpose of this study was to assess anxiety and its predictors among a sample of HCWs at the American University of Beirut Medical Center (AUBMC) and to evaluate the association between resilience and anxiety. Methods: This cross-sectional study was conducted using an online survey between March and June 2021 among HCWs at AUBMC. The psychosocial scale section included the 7-item generalized anxiety disorder (GAD-7) scale and a 25-item resilience scale, validated tools used to assess anxiety and resilience respectively. Data were analyzed on SPSS version 27, and descriptive statistics were applied. Predictors were evaluated using bivariate and multivariate linear regression. Results: From a total of 92 participants, 75% were involved in direct patient care, and of those, 95% worked directly with suspected or confirmed COVID-19 patients. The majority (83%) had minimal to mild anxiety, whereas the rest had moderate to high anxiety levels. Around 41% reported moderately high to high resilience, 47% were found to be between the low end and moderate resilience scale and only 12% had very low or low resilience. More than 80% of the participants received PPE training, reported always working with adequate preventive infection control measures, and were vaccinated. Further, more than 70% of participants reported trusting the management and agreed that the safety of the workers is considered a high priority. No significant association between sociodemographic and COVID-19 work exposure factors with anxiety was found. Multivariate analysis results showed that a lower anxiety score was associated with higher resilience (p = 0.011). Conclusion: This study has shown a strong association between low anxiety levels and high resilience scores in this group of mostly vaccinated HCWs caring for COVID-19 patients. The high percentage of vaccination along with PPE availability could explain the low anxiety levels reported among the participants.
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OBJECTIVES: Despite numerous initiatives, occupational exposure to blood-borne pathogens (BBP) caused by percutaneous injuries or mucosal contamination remain common among healthcare workers (HCWs). These exposures were decreasing at the American University of Beirut Medical Center (AUBMC) in the previous decades. Recently, the medical center activity has been increasing with higher number of interventions performed and shorter hospital stay. Our aim was to determine the trend of incidents resulting from BBP exposures at AUBMC from 2014 till 2018 and identify whether the increase in hospital activity affected the rate of these exposures. We also aimed to assess the risk factors associated with needle stick injuries (NSIs). METHODS: A retrospective observational descriptive study of all exposures to BBPs among HCWs reported to the Environmental Health, Safety, and Risk Management department at the AUBMC between 2014 and 2018 was performed. RESULTS: There were 967 exposures reported among which 84% were due to needlesticks. Residents (40%), followed by nurses (30%), and then by attending physicians (16%) were the top three most exposed occupational groups. Half of the participants injured themselves using either a syringe or a suture needle; and mostly during or after use. Occupation and incident location were associated with NSIs. The mean BBP exposure incidence rate was 5.4 per 100 full-time employees, 65.6 per 100 bed-years, and 0.48 admission-years. The BBP exposure rate per 100 occupied beds per year decreased between 2014 and 2017 then increased in 2018 (P < 0.001). The number of BBP exposures showed a strong, though non-significant negative correlation with the average length of hospital stay (Spearman correlation coefficient = -0.9, P = 0.083). CONCLUSIONS: BBP exposure remains a serious occupational hazard. Our study shows that the BBP exposure rate per 100 occupied beds per year started decreasing during the study period before increasing again in 2018. Only the nursing department showed a consistent decrease of exposures. The occupation and incident location were found to be risk factors associated with NSIs. In addition to providing education and training, additional steps such as providing safety equipment and future interventions directed towards adjusting to higher workload should be all considered.
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Patógenos Transmitidos por la Sangre , Exposición Profesional , Personal de Salud , Humanos , Líbano/epidemiología , Estudios Retrospectivos , Centros de Atención TerciariaRESUMEN
Ammonium perfluorooctanoate (APFO) exposures were estimated for use in an occupational mortality study using detailed work histories of cohort members and an exposure reconstruction model developed from occupational information and serum PFO(-) data collected in 2004 as part of a cross-sectional health survey. Measured serum PFO(-) levels of the health survey participants were linked with the job title held by the individuals at the time of sampling. The median, range, and distribution of serum levels were calculated to determine the typical exposure intensity for each job title. High variability was observed in the serum levels of workers within the same job titles. In addition, working in many "APFO-use" jobs did not result in higher exposure than working in "no APFO-use" jobs. Each job title was then assigned to one of three relative APFO job exposure categories (low, medium, or high). Participants' length of time in their job was examined in relation to their serum PFO(-) level and found unlikely to contribute to misclassification of job titles within exposure categories. The mean of the serum PFO(-) measurements for each job exposure category served as the mean intensity factor. Subsequently, the job exposure categories were applied to all historical job titles of the mortality cohort based on their correspondence with job titles represented in the health survey. The resulting job exposure matrix was validated with additional historical blood data collected between 1979 through 2002 from voluntary participants in a separate biomonitoring program. The validation analyses showed general agreement between estimated and measured exposure, reflecting the within-job-title variability observed in measured serum levels used to classify job exposure.
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Caprilatos/sangre , Fluorocarburos/sangre , Exposición Profesional/análisis , Biomarcadores/sangre , Estudios de Cohortes , Estudios Transversales , Monitoreo del Ambiente , Mortalidad , Exposición Profesional/clasificación , Ocupaciones/clasificaciónRESUMEN
PURPOSE: Based on previous reports of increased serum lipid levels in workers at a U.S. polymer manufacturing facility, the study objective was to investigate ischemic heart disease (IHD) mortality as well as a broad range of mortality causes for an occupational cohort at the facility. METHODS: The cohort comprised 6,027 men and women who had worked at the facility between 1948 and 2002; these years delimit the mortality follow-up period. Standardized mortality ratios (SMR) were estimated to compare observed numbers of deaths to expected numbers derived from mortality rates for 3 reference populations: the U.S. population, the West Virginia state population, and an 8-state regional employee population from the same company. RESULTS: Most SMR estimates based on U.S. and state populations were below 100. Comparison to the employee population also resulted in many SMR estimates at or near a no-effect level. Relative to the regional worker population, a nonsignificant elevation for IHD mortality was observed (SMR = 109, 95% confidence interval [CI]: 96, 124). Mortality associated with diabetes was significantly increased compared to the regional worker population (SMR = 197, 95% CI: 123, 298). A corresponding increase in the SMR for IHD and diabetes mortality was not detected for comparisons with the two general populations. CONCLUSIONS: The results reported herein show little evidence of increased cause-specific mortality risks for workers at the plant. This study demonstrates the utility of comparing occupational cohorts with a similar worker reference population in order to reduce bias associated with the healthy worker effect.
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Industria Química , Enfermedades Profesionales/mortalidad , Adulto , Estudios de Cohortes , Diabetes Mellitus/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/mortalidad , Enfermedades Profesionales/inducido químicamente , Exposición Profesional/efectos adversos , Estudios Retrospectivos , Estados Unidos , Recursos HumanosRESUMEN
OBJECTIVE: To investigate the effect of union status on injury risk among a large industrial cohort. METHODS: The cohort included hourly employees at 19 US plants between 2000 and 2007. Plants were classified by union status, and injuries were classified by severity. Cox-proportional hazard shared frailty model was used to determine time to first reportable injury. RESULTS: A total of 26,462 workers were included: 18,955 (72%) unionized and 7507 (28%) non-unionized. Union workers incurred 3194 injuries (16.9%) compared with 618 injuries for non-union workers (8.2%). After adjusting for multiple covariates, union workers had a 51% higher risk of reportable injury. CONCLUSIONS: Our results provide evidence for higher risk of reportable injuries in union workers; explanations for this increased risk remain unclear.
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Empleo/estadística & datos numéricos , Sindicatos/estadística & datos numéricos , Traumatismos Ocupacionales/epidemiología , Adulto , Factores de Edad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Salud Laboral , Modelos de Riesgos Proporcionales , Factores de Riesgo , Factores de Tiempo , Índices de Gravedad del Trauma , Lugar de Trabajo/estadística & datos numéricosRESUMEN
OBJECTIVE: To examine the relationship between serum perfluorooctanoate (PFOA), a biomarker of ammonium perfluorooctanoate (APFO) exposure, and lipids and liver enzymes in a cross-sectional study among workers with potential occupational exposure to APFO. METHODS: We conducted a cross-sectional study of 1,025 active workers with potential exposure to APFO using linear regression to examine the relationship between PFOA and selected outcomes from a standard metabolic health screening survey, emphasizing lipids and liver enzymes. RESULTS: Most outcome parameters were within normal limits. After adjusting for potential confounders, we observed a modest but statistically significant, positive relationship between serum PFOA and total cholesterol, low-density lipoprotein (LDL), very low-density lipoprotein (VLDL), and gamma glutamyl aminotransferase (GGT). No associations were seen for high-density lipoprotein (HDL) or bilirubin; associations with AST (aspartate aminotransferase) and ALT (alanine transpeptidase) did not reach statistical significance. CONCLUSIONS: Our findings indicate a modest positive association of PFOA on some lipid parameters and a need for follow-up studies.
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Fluorocarburos/envenenamiento , Encuestas Epidemiológicas , Lípidos/análisis , Hígado/enzimología , Exposición Profesional , Adulto , Biomarcadores/sangre , Estudios de Cohortes , Estudios Transversales , Delaware , Femenino , Fluorocarburos/análisis , Humanos , Modelos Lineales , Masculino , Persona de Mediana EdadRESUMEN
Approximately 440,000 U.S. Veterans receive compensation for back and/or neck conditions. Veterans Benefits Administration (VBA) criteria state that back compensation determinations are based on impaired back function and not comorbidity or lifestyle, but whether compensation is based solely on consideration of the lumbosacral region is unknown. In this study, we conducted a cross-sectional analysis of medical chart data from 178 post-9/11 Veterans applying for service connection for back pain in fiscal year 2012 at the Department of Veterans Affairs Connecticut Healthcare System. Altogether, 62% were noted to have impairment of back functioning and 74% were awarded compensation. Rates of comorbidities (obesity, depression, smoking, and illicit drug use) were high. In multivariate models predicting compensation awarded, only having an impaired back was associated with service-connected compensation. Pain was associated with extent of service connection, but this relationship was fully mediated by functional back impairment. No other measure (including work status) significantly predicted compensation. In summary, service connection was largely based on functional impairment, as called for in VBA criteria. Although pain and comorbidities undoubtedly affect day-to-day functioning, these factors were not independently related to service connection. Veterans present with many remediable conditions, and the service-connection evaluation may be an opportunity to engage them in treatment.
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Exposición a Riesgos Ambientales/efectos adversos , Armas de Fuego , Intoxicación por Plomo/etiología , Adulto , Anciano , Biomarcadores/sangre , Connecticut , Humanos , Plomo/sangre , Intoxicación por Plomo/sangre , Intoxicación por Plomo/diagnóstico , Masculino , Persona de Mediana Edad , Vigilancia en Salud PúblicaRESUMEN
OBJECTIVES: Several adverse pregnancy outcomes were reported among female laboratory workers in a North American aluminum smelter. To determine whether these outcomes were associated with any occupational exposure at the plant, a cross-sectional survey was undertaken. METHODS: Rates of miscarriage, premature singleton birth, and major congenital anomaly occurring during employment were compared with a reference group comprised of all pregnancies that occurred before employment. RESULTS: Among female workers, the excess of congenital anomalies among female laboratory workers that defined the initial cluster was observed, but no specific pattern was found. CONCLUSIONS: On the basis of these analyses, the increase in congenital anomalies could not be attributed to occupational exposures at the smelter nor could potential exposure likely explain the diverse anomalies described.
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Aluminio/efectos adversos , Metalurgia , Exposición Profesional/efectos adversos , Resultado del Embarazo/epidemiología , Aborto Espontáneo/epidemiología , Adulto , Distribución de Chi-Cuadrado , Anomalías Congénitas/epidemiología , Estudios Transversales , Femenino , Humanos , Modelos Logísticos , Masculino , Personal de Laboratorio Clínico/estadística & datos numéricos , Análisis Multivariante , Oportunidad Relativa , Embarazo , Nacimiento Prematuro/epidemiología , Factores Sexuales , Factores de Tiempo , Recursos HumanosRESUMEN
OBJECTIVE: The investigation updates the mortality experience through 2002 for a cohort of workers exposed to acrylonitrile (AN). METHODS: Standardized mortality ratios (SMR) were estimated based on two reference populations: the US population and a regional employee population. Exposure-response analyses were conducted using Cox regression models for cumulative and mean intensity exposure measures. RESULTS: In the cohort of 2548 workers, 839 deaths have occurred with 91 deaths due to respiratory system cancer. Most standardized mortality ratio estimates are at or near no-effects levels. Hazard ratio (HR) estimates indicate no increased mortality risk for respiratory system cancer (adjusted HR = 0.96, 95% confidence interval: 0.74, 1.25). CONCLUSIONS: In summary, no mortality outcome of a priori interest, principally respiratory system cancer, is associated with increased AN exposure among fiber production workers over five decades of follow-up.
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Acrilonitrilo/efectos adversos , Carcinógenos , Industria Química , Neoplasias/inducido químicamente , Exposición Profesional/efectos adversos , Acrilonitrilo/análisis , Adolescente , Adulto , Carcinógenos/análisis , Causas de Muerte , Estudios de Cohortes , Estudios de Seguimiento , Efecto del Trabajador Sano , Humanos , Masculino , Persona de Mediana Edad , Fibras Minerales/efectos adversos , Neoplasias/mortalidad , Exposición Profesional/análisis , Modelos de Riesgos Proporcionales , Neoplasias del Sistema Respiratorio/inducido químicamente , Neoplasias del Sistema Respiratorio/mortalidad , South Carolina/epidemiología , Virginia/epidemiologíaRESUMEN
OBJECTIVE: To examine the relationship between serum perfluorooctanoate (PFOA), a biomarker of ammonium perfluorooctanoate exposure, and lipids and liver enzymes. METHODS: We conducted a longitudinal study on 454 workers and used mixed models to examine the relationship between serum PFOA and lipids and liver enzymes. RESULTS: One part per million (ppm) increase in serum PFOA was associated with a 1.06 mg/dL increase in total cholesterol, but was not associated with changes in triglycerides or other lipoproteins, after adjusting for potential confounders. Serum PFOA was also associated with total bilirubin (0.008 mg/dL decline/ppm) and serum aspartate aminotransferase (0.35 units increase/ppm) but not with the other liver enzymes. CONCLUSIONS: These medical surveillance data collected on workers for up to 25 years contributes useful information on the effects of ammonium perfluorooctanoate exposure on human liver and lipid chemistry.