Safety and effectiveness of disease-modifying therapies after switching from natalizumab.

INTRODUCTION: One strategy to mitigate progressive multifocal leukoencephalopathy (PML) risk is to switch to other highly effective disease-modifying therapies (DMTs). However, the optimal switch DMT following natalizumab (NTZ) discontinuation is yet to be determined. OBJECTIVE: The objective of the study is to determine the most effective and tolerable DMTs to switch to following NTZ discontinuation due to John Cunningham virus (JCV) antibody positivity. METHODS: This is a multicenter observational cohort study that included all stable relapsing-remitting multiple sclerosis (MS) patients who were treated with NTZ for at least 6 months before switching therapy due to JCV antibody positivity. RESULTS: Of 321 patients, 255 switched from NTZ to rituximab/ocrelizumab, 52 to fingolimod, and 14 to alemtuzumab, with higher annualized relapse rate (ARR) in fingolimod switchers (0.193) compared with rituximab/ocrelizumab or alemtuzumab (0.028 and 0.032, respectively). Fingolimod switchers also had increased disability progression (p = 0.014) and a higher proportion developed magnetic resonance imaging (MRI) lesions compared with rituximab/ocrelizumab (62.9% vs. 13.0%, p < 0.001, and 66.6% vs. 24.0%, p < 0.001, respectively). Mean drug survival favored rituximab/ocrelizumab or alemtuzumab over fingolimod (p < 0.001). CONCLUSION: Our study shows superior effectiveness of rituximab/ocrelizumab and alemtuzumab compared with fingolimod in stable patients switching from NTZ due to JC virus antibody positivity.

Predictors of drug-resistant epilepsy in childhood epilepsy syndromes: A subgroup analysis from a prospective cohort study.

OBJECTIVE: Previous studies assessing factors associated with drug-resistant epilepsy (DRE) were constrained by their amalgamation of all epilepsy syndromes in their analyses and the absence of uniform criteria for defining DRE. Our objective was to identify predictors of DRE among the four primary childhood epilepsy syndrome groups within a cohort of children with new onset seizures, using the International League Against Epilepsy (ILAE) definition of DRE and the recent classification of epilepsies. METHODS: This is a prospective study of 676 children with new onset seizures initiated on antiseizure medication. Patients were monitored for the occurrence of DRE according to the ILAE criteria and were categorized into one of four epilepsy groups: self-limited focal epilepsies (SeLFEs), genetic generalized epilepsies (GGEs), developmental epileptic encephalopathies (DEEs), and focal epilepsies. Cox regression analysis was performed to identify predictors of DRE within each epilepsy group. RESULTS: Overall, 29.3% of children were classified as having DRE, with the highest incidence observed among children diagnosed with DEEs (77.7%), followed by focal epilepsies (31.5%). Across the entire cohort, predictors of DRE included the presence of an epileptogenic lesion, a higher pretreatment number of seizures, experiencing multiple seizure types, presence and severity of intellectual and developmental delay, myoclonus, and younger age at epilepsy onset. Within the GGEs, only a younger age at seizure onset and experiencing multiple seizure types predicted DRE. Among focal epilepsies, predictors of DRE included the presence of an epileptogenic lesion, experiencing multiple seizure types, and having a greater number of pretreatment seizures. Within the DEEs, predictors of DRE were the occurrence of tonic seizures. Predictors of DRE within SeLFEs could not be identified. SIGNIFICANCE: This study indicates that different epilepsy syndromes are associated with distinct predictors of drug resistance. Anticipation of drug resistance within various groups is feasible using accessible clinical variables throughout the disease course.

Knowledge of epilepsy, quality of life, and psychiatric comorbidities in Lebanese adults with epilepsy.

INTRODUCTION: People with epilepsy (PWE) face a variety of psychosocial challenges. A lack of knowledge of epilepsy, a high level of depression and anxiety and a low quality of life (QoL) are among the major problems that affect most PWE. The objective of this study was to examine the association of sociodemographic characteristics, clinical factors and knowledge of epilepsy with the level of QoL, and the presence of psychiatric comorbidities. METHOD: A cross-sectional study was conducted in Lebanon. The PWE were recruited from neurologists' clinics in Beirut and its suburbs. A questionnaire translated into Arabic was used and composed of four parts: sociodemographic factors, clinical characteristics, psychosocial characteristics (QoL, psychiatric disorders), and knowledge epilepsy scale. Backward logistic regression models were developed, the associations were estimated by odds ratio (OR), and the level of significance was set at p ≤ 0.05. RESULTS: Four hundred and four PWE were recruited in this study. About a half of PWE had controlled epilepsy (46.3 %) and 40.3 % had epilepsy for less than 5 years. The QoL was low for 38.6 % of PWE and 30.2 % had psychiatric comorbidities. More than half of PWE had a good level of knowledge (71.5 %). Controlled epilepsy (OR = 1.8; 95 %CI: 1.2-2.9), and good knowledge about epilepsy (OR = 5.5; 95 %CI: 3.4-9.1) were associated with better QoL. Patients on polytherapy with anti-seizure drugs (OR = 0.6; 95 %CI: 0.4-0.9), experienced side effects of anti-seizure drugs (OR = 0.6; 95 %CI: 0.4-0.9) and with psychiatric comorbidities (OR = 0.6; 95 %CI: 0.3-0.9) had a lower QoL. A high number of nonpsychiatric comorbidities (OR = 2.5; 95 %CI: 2.0-3.1) and a polytherapy increased the risk of having psychiatric comorbidities (OR = 1.8; 95 %CI: 1.1-2.8). CONCLUSIONS: Good knowledge of epilepsy and the absence of psychiatric comorbidities are important predictors of good QoL in Lebanese PWE. Educational programs are needed to reduce misconceptions about epilepsy and improve mental health of PWE.

Management of epilepsy in Lebanon: Medication reviews and drug-related problems.

PURPOSE: The goal of epilepsy treatment is to control seizures without drug related problems (DRPs). The evaluation of anti-seizure drugs (ASD) strategies and identification of DRPs are rarely studied. This study aimed primarily to evaluate the choice of ASD according to international guidelines and secondarily to identify and describe anti-seizure drug-related problems. METHODS: A cross-sectional study was conducted during 1 year among Lebanese adults with epilepsy attending neurology clinics. The choice of ASD was compared to National Institute for Health and Care Excellence guidelines. Drug-drug interactions were evaluated by the Lexicomp database, and the DRP classification was performed using the Pharmaceutical Care Network Europe classification. RESULTS: A total of 404 patients with epilepsy were included. The prescription for an ASD was in accordance with the indication set in guidelines in 75.0% of population, and 1078 DRPs were identified. The main DRPs detected were adverse drug reactions (51.0%), inappropriate combinations of drugs (50.0%), and suboptimal drug regimens (46.3%). Single and divorced patients, who living in Mount Lebanon, and who took the old with the new generation had a less risk to have an inadequate prescription to guidelines. However, female gender, controlled epilepsy, multiple ASDs, and living in a rural region increased DRPs. CONCLUSIONS: This study showed that quarter of the population used ASDs contraindicated according to international guidelines. Since DRPs were related to the number and type of ASD prescribed, it is important to assess the case of each patient by a clinical pharmacist to prevent drug-drug interactions and iatrogenic issues.

Ability to detect potentially inappropriate prescribing in older patients: comparative analysis between PIM-Check and STOPP/STARTv2.

PURPOSE: Potentially inappropriate prescribing (PIP) is a source of preventable adverse drug events. The objective of this study was a comparative analysis (quantitative and qualitative) between two tools used to detect PIP, PIM-Check and STOPP/START. METHODS: First, a qualitative analysis (QAC) was conducted to evaluate the concordance between the criteria, which constitute PIM-Check and the gold standard STOPP/START. Second, a retrospective comparative and observational study was performed on the list of treatment at the admission of 50 older patients hospitalized in an acute geriatric ward of a university hospital in Switzerland in 2016 using both tools. RESULTS: The QAC has shown that 50% (57 criteria) of STOPP/START criteria are fully or partially concordant with those of PIM-Check. The retrospective study was performed on 50 patients aged 87 years, suffering from 5 co-morbidities (min-max 1-11) and treated by of 8 drugs (min-max 2-16), as medians. The prevalence of the detected PIP was 80% by PIM-Check and 90% by STOPP/START. Medication review shows that 4.2 PIP per patient were detected by PIM-Check and 3.5 PIP by STOPP/START among which 1.9 PIP was commonly detected by both tools, as means. PIM-Check detected more PIP related to cardiology, angiology, nephrology, and endocrinology in older patients but missed the PIP related to geriatric syndromes (e.g., fall, dementia, Alzheimer) detected by STOPP/START. CONCLUSIONS: By using PIM-Check in geriatric settings, some PIP will not be detected. It is considered as a limitation for this tool in this frail population but brings a certain complementarity in other areas of therapy not covered by STOPP/START.

Clinical and economic impacts of explicit tools detecting prescribing errors: A systematic review.

WHAT IS KNOWN AND OBJECTIVE: Many explicit tools have been developed to reduce prescribing errors and ensure patients' safety. The impact of explicit tools is not well studied. The objective of this study was (a) to conduct a systematic review of systematic reviews listing explicit tools developed to detect prescribing errors and (b) to assess their impact on clinical and economic outcomes. METHODS: This project includes two related parts. First, a systematic review of systematic reviews listing explicit tools dedicated to geriatrics or internal medicine was performed to develop an exhaustive list of explicit tools. Then, using the list compiled in the first step, a systematic review of randomized controlled trials (RCT) assessing clinical or economic impacts of tools was performed to evaluate their usefulness. RESULTS AND DISCUSSION: The systematic review of systematic reviews identified 49 explicit tools. The systematic review of RCT, using one or more of the 49 explicit tools, identified 5 RCT using explicit tools as intervention (3 STOPP/START and 2 FORTA RCT). The 5 studies evaluated clinical impacts with 3 RCT identifying significant clinical impacts (falls, activities of daily living and/or adverse drug reactions) and 2 STOPP/START RCT identifying significant economic impacts. WHAT IS NEW AND CONCLUSION: The systematic review of RCT showed that explicit tools can have some effect in improving patients' safety. Further studies are warranted to better characterize their clinical and economic impact.

Impact of Pharmaceutical Interventions in Hospitalized Patients: A Comparative Study Between Clinical Pharmacists and an Explicit Criteria-Based Tool.

BACKGROUND: It has been well recognized that pharmaceutical interventions (PIs) can prevent patient harm related to prescribing errors. Various tools have been developed to facilitate the detection and the reduction of inappropriate prescriptions and some have shown benefit on clinical outcomes. OBJECTIVE: The objective of this study was to evaluate the clinical, economical, and organizational impact of interventions generated by clinical pharmacists in hospitalized patients, and to evaluate the performance of an explicit tool, the Potentially Inappropriate Medication Checklist for Patients in Internal Medicine (PIM-Check), in detecting each pharmacist's intervention. METHODS: A cohort retrospective study was conducted on hospitalized patients. The impact of PIs based on pharmacists' standard examination was evaluated using the Clinical, Economic, and Organizational (CLEO) tool. The performance of PIM-Check in detecting each intervention was assessed by conducting a retrospective medication review based on available information collected from patients' records. A qualitative analysis was also conducted to identify the types of PIs that PIM-Check failed to detect. RESULTS: The study was performed on 162 patients with a median age of 68 years (interquartile range = 46-77 years) and a median hospital stay of 5 days (interquartile range = 4-7 days). The pharmacists generated 1.9 PIs per patient (n = 304) of which 31% were detected by PIM-Check. The acceptance rate of the interventions by physicians was 84% (n = 255). Among the accepted interventions, 53% (n = 136) had a clinical impact graded CL ≥ 2C (moderate or major), whereas the majority of them were not detected by PIM-Check (63%; 86 out of 136). In addition, 46% of accepted interventions (n = 117) were associated with a cost decrease, among which 62% were not detected by PIM-Check (73 out of 117). The qualitative analysis shows that PIM-Check mostly failed to detect PIs related to dose adjustment, overprescribing, and therapy monitoring. CONCLUSIONS: According to the CLEO tool evaluation of PIs, our results show that clinical pharmacists' interventions are associated with improved clinical outcomes. In comparison with pharmacists' interventions, PIM-Check failed in detecting the majority of interventions associated with a moderate or major impact.

Self-reported attitudes about medication in Lebanese people with epilepsy.

BACKGROUND: Epilepsy is a common worldwide neurological disorder. For people with epilepsy (PWE), adherence and attitudes towards medication is a crucial step to improve efficacy of prescribed treatment and to prevent seizures. OBJECTIVES: The first aim of this study was to evaluate attitudes towards antiepileptic medications in Lebanese population. Secondary aims were to assess factors affecting attitudes and associated with epilepsy control. MATERIAL AND METHODS: A cross-sectional study was conducted in outpatient neurology clinics located in Beirut-Lebanon. Data were collected using a structured questionnaire. Self-report of medication taking behaviors were assessed using the abbreviated (4 items) Morisky Medication Adherence Scale (MMAS-4). Epilepsy was considered as controlled if the patient had no seizures in the last 6 months. RESULTS: Among 250 PWE recruited in this study, male-to-female ratio was 0.87 (116/134), and 50.8% were married. Mean duration of epilepsy was 13.7 ±â€¯12.8 years. Valproate was the most common antiepileptic drug (AED) used followed by levetiracetam and carbamazepine. About 60.8% of the population presented partial epilepsy. Uncontrolled epilepsy was present in more than half of participants (55.2%), with only 32.4% had positive attitudes to their medication. Positive attitudes towards antiepileptic increased in people who found that their treatment was efficacious (odds ratio (OR) = 4.9; 95% confidence interval (CI): 1.2-20.0; p = 0.03), who had controlled epilepsy (OR = 3.4; 95%CI 1.6-7.1; p = 0.001), and who were diagnosed as PWE between the age of 12-20 years (OR = 3.1; 95%CI 1.1-8.4; p = 0.03). Oppositely, these attitudes decreased in participants who felt their treatment as an economic burden (OR = 0.2; 95%CI 0.1-0.4; p ≪ 0.001), and in people with depression (OR = 0.4; 95%CI 0.2-0.9; p = 0.04). Controlled epilepsy was higher in people who contacted a neurologist if seizure occurred, in people with positive attitudes, and after a long duration of disease, but it decreased if patient did not follow neurologist's instructions in fasting period. CONCLUSIONS: Lebanese PWE were less likely to have positive attitudes towards medication, which may lead to poor epilepsy control. Depression and economic burden were the major factors that decreased these attitudes. Identifying factors affecting attitudes to medication and leading to controlled epilepsy may help clinicians to elaborate educational programs to optimize medication adherence.

Waterpipe effects on pulmonary function and cardiovascular indices: a comparison to cigarette smoking in real life situation.

INTRODUCTION: Smoking is known to have physiological effects on biological systems. The purpose of this study is to evaluate acute and chronic effects on pulmonary functions and cardiovascular indices of waterpipe (WP) smoking in real life circumstances. METHODS: Three groups were included in the study: non-smokers (N = 42), WP smokers (N = 42) and cigarette smokers (N = 48). A questionnaire was completed for each participant, in addition to pulmonary function [forced expiratory volume at 1 s (FEV1), 6 s (FEV6), percentage of FEV1/FEV6], and cardiovascular [diastolic blood pressure (DBP), systolic blood pressure (SBP) and heart rate (HR)] measures, taken before and after smoking. RESULTS: Mean values of FEV1, FEV6, FEV1/FEV6, DBP and SBP in WP and cigarette smokers were very close. However, WP smoking significantly increased HR compared to cigarette smokers (p = 0.007); duration of smoking, age at first WP and quantity of smoking affected pulmonary function and cardiovascular values. In the subgroup of WP smokers, DBP was acutely increased by a larger WP size (p = 0.011), while the FEV6 was acutely increased by a smaller WP size (p = 0.045). CONCLUSION: WP smoking affected the cardiovascular system more than cigarette smoking, while it had similar effects on pulmonary function.

Disease-modifying therapies, outcomes, risk factors and severity of COVID-19 in multiple sclerosis: A MENACTRIMS registry based study.

BACKGROUND: There is a lack information regarding risk factors associated with worse COVID-19 outcomes in patients with multiple sclerosis (MS) in the MENA region. METHODS: This is a multicenter, retrospective cohort study that included all MS patients with a suspected or confirmed COVID-19 infection using the MENACTRIMS registry. The association of demographics, disease characteristics, and use of disease-modifying therapies (DMTs) with outcomes and severity of COVID-19 were evaluated by multivariate logistic model. RESULTS: A total of 600 MS patients with confirmed (n = 542) or highly suspected (n = 58) COVID-19 were analyzed. Seventy-three patients (12.2 %) had a COVID-19 severity score of ≥3 on a 7-point ordinal scale (ranging from 1 [not hospitalized with no limitations on activities] to 7 [death] with a cutoff at 3 [hospitalized and not requiring supplemental oxygen]), and 15 patients (2.5 %) died. Out of 73 patients with a severity score ≥3, 90.4 % were on DMTs; 50.6 % of them were on anti-CD20, including ocrelizumab and rituximab. Multivariate logistic regression showed that older age (odds ratio per 10 years, 1.4 [95 %CI, 1.0-1.8]), disability (OR for EDSS 3.0-5.5, 2.9 [95 %CI. 1.5-5.7], OR for EDSS ≥6.0, 2.3 [95 %CI. 1.0-5.1]), obesity (OR, 3.0 [95 %CI, 1.5-6.0]), and treatment with rituximab (OR, 9.0 [95 %CI, 3.1-25.3]) or off-label immunosuppressive medications (OR, 5.6 [95 %CI. 1.1-27.8]) were risk factors for moderate or severe COVID-19. CONCLUSION: In this registry-based study of MS patients, age, sex, EDSS, obesity, progressive MS were risk factors for severe COVID-19. Moreover, there was an association found between exposure to anti-CD20 DMTs and COVID-19 severity.

Barriers to accessing multiple sclerosis disease-modifying therapies in the Middle East and North Africa region: A regional survey-based study.

BACKGROUND: Multiple sclerosis (MS) management varies markedly between different countries of the Middle East and North Africa (MENA) region based on the availability and accessibility of disease-modifying therapies (DMTs). OBJECTIVE: To evaluate the accessibility to DMTs in each MENA country, identify barriers to treatment and make recommendations for improved access to DMTs across the region. METHODS: This is a descriptive, survey-based study whereby we extracted data collected, between October 2019 and April 2020, for countries in the MENA region by the Multiple Sclerosis International Federation (MSIF) through their Atlas of MS survey. RESULTS: 16 out of 19 countries in the MENA region were included in this study. Sudan and Syria did not have any originator DMTs approved. Interferons were the most widely low-efficacy originator approved DMTs. Three countries did not have any high efficacy DMTs approved. Moreover, follow-on DMTs were approved in half (50%) of the countries. Cost of treatment was the most important barrier, reported in nearly half (47%) of the MENA countries. CONCLUSION: Although most MENA countries have access to DMTs, more than half of countries report problems with treatment continuation, highlighting the need for a targeted regional strategy to address the variations in access to MS treatments.

Early predictors of remission in children and adolescents with new-onset epilepsy: A prospective study.

PURPOSE: This study aims to identify predictive factors of a two-year remission (2YR) in a cohort of children and adolescents with new-onset seizures based on baseline clinical characteristics, initial EEG and brain MRI findings. METHODS: A prospective cohort of 688 patients with new onset seizures, initiated on treatment with antiseizure medication was evaluated. 2YR was defined as achieving at least two years of seizure freedom during the follow-up period. Multivariable analysis was performed and recursive partition analysis was utilized to develop a decision tree. RESULTS: The median age at seizure onset was 6.7 years, and the median follow-up was 7.4 years. 548 (79.7%) patients achieved a 2YR during the follow up period. Multivariable analysis found that presence and degree of intellectual and developmental delay (IDD), epileptogenic lesion on brain MRI and a higher number of pretreatment seizures were significantly associated with a lower probability of achieving a 2YR. Recursive partition analysis showed that the absence of IDD was the most important predictor of remission. An epileptogenic lesion was a significant predictor of non-remission only in patients without evidence of IDD, and a high number of pretreatment seizures was a predictive factor in children without IDD and in the absence of an epileptogenic lesion. CONCLUSION: Our results indicate that it is possible to identify patients at risk of not achieving a 2YR based on variables obtained at the initial evaluation. This could allow for a timely selection of patients who require close follow-up, consideration for neurosurgical intervention, or investigational treatments trials.

Medication prescribing errors: data from seven Lebanese hospitals.

INTRODUCTION: Medication prescribing errors are made all over the world. However, exact data about them are lacking in Lebanon. Our objective was to describe medication errors, including drug-drug interactions in medication orders given to patients admitted to Lebanese hospitals. METHODS: A prospective study was carried out on 313 patients taken from seven Lebanese hospitals; 1826 medication orders were assessed for errors and 456 drug-drug interactions were found. Data was entered and analyzed on SPSS. RESULTS: Around 40% of medication orders were judged to comprise at least one prescribing error, mainly no ordering of parameters monitoring (20%), unnecessary medication (9%), and no indication (7%). Errors occurred mainly in the pediatrics (50%) and internal medicine wards (40%). Having an infectious or gastrointestinal problem almost doubled the risk of medication prescribing error. Antiulcer agents, NSAIDs, antibiotics and steroidal agents were the medications mainly involved. Meanwhile, 12 adverse medication events were reported, with an odds ratio of association to a medication error of 7.4 (p = 0.004). As for drug-drug interaction (DDI), prescriptions comprised zero to 29 interactions, involving medications with low margin of safety such as acenocoumarol, amiodarone and valproate. Pharmacodynamic interactions were mainly found (60%). The majority of DDI were of high clinical significance and well documented (80%), with moderate (59%) to major (17%) severity. CONCLUSION: These results highlight the urgency of an intervention to improve patients' outcomes and avoid deleterious impact of inadequate medication use in Lebanon. The presence of a clinical pharmacist, the inclusion of computerized systems and the application of drug management policies are suggested to decrease medication prescribing errors and enhance the physician attention to DDI.

Impact of Pharmaceutical Interventions with STOPP/START and PIM-Check in Older Hospitalized Patients: A Randomized Controlled Trial.

INTRODUCTION: Pharmaceutical interventions can reduce negative outcomes related to potentially inappropriate prescriptions (PIPs). OBJECTIVE: The objective of this study was to compare the impact of interventions on the reduction of PIPs and on different clinical outcomes using two electronic explicit tools. METHODS: A randomized controlled trial was conducted in patients hospitalized between 2018 and 2019 at the Acute Care for Elders unit at Lausanne University Hospital in Switzerland. A medication review was conducted using PIM-Check in the first arm and STOPP/START in the second arm. Proposed interventions were communicated to the physicians. Clinical outcomes evaluated were incidence of falls, delirium, activities of daily living (ADL), length of stay, number of drugs at discharge and hospital readmission. RESULTS: The 123 included patients (60 in the first arm and 63 in the second arm) were 86.3 ± 6.6 years old, had 3.5 ± 1.7 diseases and were treated by 6.2 ± 2.7 drugs at admission. There was a significant decrease in PIPs in each arm, but no significant difference between arms. The deprescription of nervous system drugs was significantly higher with STOPP/START than with PIM-Check (Chi-square p = 0.025). ADL scores between home and discharge were significantly higher in the STOPP/START arm than in the PIM-Check arm (4.42 vs 3.77; p = 0.040). The predictors of ADL score improvement were the deprescription of nervous system drugs (ß = 0.423; 95% CI 0.034-0.812; p = 0.033), the use of STOPP/START (ß = 0.798, 95% CI 0.305-1.290; p = 0.002) and a shorter length of hospital stay (ß = -0.033, 95% CI - 0.056 to - 0.010; p = 0.005). CONCLUSIONS: Although PIM-Check was non-inferior to STOPP/START in reducing the number of PIPs, STOPP/START had a significantly higher impact on ADL. The use of STOPP/START or the deprescription of two nervous system drugs would allow the patient to acquire almost one more basic function of living. On the other hand, a loss of one point on the ADL score was observed per month of hospitalization. CLINICAL TRIALS REGISTRATION NUMBER: NCT04028583.

Lebanese Hospital-Based Rheumatoid Arthritis Registry: Characteristics of Patients and Comparison with Other Populations.

Objectives: The aim of the Lebanese hospital-based Rheumatoid Arthritis (RA) registry, initiated in 2011, is to evaluate the safety and efficacy of biologic agents among patients seeking care at the American University of Beirut Medical Center (AUBMC). We aimed to characterize the demographic and clinical profile of RA patients included in the Lebanese registry. We compared our results with those issued from Middle Eastern and non-Middle Eastern registries. Methods: 195 Patients enrolled in the RA registry from 2011 to 2018 were considered in this study. Patients enrolled in the registry were eligible to be treated with biologics, but 56 patients remained biologics naïve. Patients were reassessed every six months. Results: The highest proportion of patients were female (81%). The mean age was 55.53±15 years, and the disease duration was 11.38±7.7 years. RA was diagnosed at a mean age of 44.13±16 years. Almost one-third of RA patients were smokers (29.2%) and 15% consumed alcohol. Comorbidities included cardiac diseases (30.8%), hypertension (24.6%), hyperlipidemia (11.8%), diabetes mellitus (9.2%), and Hypothyroidism (6.2%). Three cases of cancer and seven cases of tuberculosis were reported. The mean of the Disease Activity Score (DAS28) was 3.75 ± 2.28 with no difference according to gender; the mean of the Health Assessment Questionnaire (HAQ) score showed a significant difference between females and males (1.02 ± 0.84 and 0.61 ± 0.7 respectively). Methotrexate was the most commonly used medication. There was non-significant difference in taking biologics according to gender. Conclusion: Our findings are similar to other studies in terms of gender distribution. The higher mean age at diagnosis compared to other populations could indicate a delay in seeking appropriate care. The Lebanese RA registry provides valuable data on pharmacological interventions used and an opportunity to follow up to examine the effectiveness of different therapeutics and to monitor their side effects.

Willingness to Pay for a Coronavirus Vaccine and Its Associated Determinants in Lebanon.

OBJECTIVES: This study aimed to investigate the willingness to pay (WTP) for a hypothetical vaccine and its associated determinants among the Lebanese general population during one of the peak episodes during the coronavirus disease 2019 (COVID-19) pandemic in Lebanon. METHODS: An online survey was developed and delivered to the Lebanese general population. The questionnaire included the participants' sociodemographic characteristics, financial situation, attitude toward vaccination, and WTP for the hypothetical vaccine. The study was based on the contingent valuation method. RESULTS: Among 500 individuals solicited, 352 individuals agreed to participate (participation rate = 70.4%); among them, 66% were between 18 and 45 years old, and 54% were women. Notably, 78.1% of the respondents were ready to pay for this hypothetical vaccine even if the vaccine will not be covered. The maximum WTP of the Lebanese population was approximately $60 ± $66 (range $3-$500) after excluding extreme values in the sensitivity analysis and ranged between $3 and $500. WTP was associated with the severity of COVID-19 (P<.001), the education level (P=.001), and the place to live during the lockdown (P=.045). There was an association between family income and WTP (P=.004) with a weak correlation. CONCLUSIONS: The WTP was comparable with other studies and highly associated with the level of education, the household income, living in the city during the lockdown, and the perceived severity of COVID-19. These findings can help in understanding COVID-19 vaccination acceptance and WTP in Lebanon.

Adherence to the Mediterranean diet decreases the risk of stroke in the Lebanese population: a case-control study.

OBJECTIVE: The objective of this study was to assess adherence to the Mediterranean diet (MeD) and the risk of stroke in the Lebanese population. METHODS: A hospital based case-control study was conducted in Lebanon between January 1st, 2015 and December 31st, 2016. Data were collected prospectively using a standardized questionnaire. Adherence to the MeD was assessed based on the total number of points a patient can have on the MeD scale. Data were analysed using SPSS version 24. The strength of association between the risk of stroke and adherence to MeD was expressed in odds ratio (OR) through 95% confidence interval. P-value <0.05 determined statistical significance. RESULTS: Around 205 stroke cases and 445 hospitalized stroke-free patients were included in this study. In the total study sample, the MeD had a minimum of 2 and a maximum of 11 points with a median of 7 points. Stroke patients had a lower MeD median compared to controls (6 vs 8 points). Around 29.5% of the total sample had a MeD score within the first quartile (52.3% of them had a stroke) and 24% of all included subjects scored within the last quartile (7% of them hospitalized for stroke) (p<0.001). The higher the adherence to MeD the lower the risk of stroke. High adherence to MeD was associated with a decreased risk of stroke, OR 0.1 (95%CI, 0.04-0.24; p<0.001). CONCLUSIONS: Higher adherence to MeD significantly decreases the risk of stroke in the Lebanese population. Good lifestyle choices are encouraged in order to prevent many vascular diseases including stroke.

Public awareness of environmental risk factors of cancer and attitude towards its prevention among the Lebanese general population.

INTRODUCTION: Since the majority of cancers occur as a result of modifiable risk factors, cancer is being seen more as a preventable disease. The primary objective of our study was to assess the level of awareness of environmental risk factors of cancer among the Lebanese general population. The secondary objective focused on identifying the predictors of the preventability of the disease. METHODS: We conducted a cross-sectional study between June and July 2020. An online questionnaire was used to collect data pertaining to the knowledge of environmental risk factors of cancer, source of information and personal practice of the participants. Bivariate and multivariate analyzes were performed. RESULTS: About 387 respondents agreed to participate in the study. The study showed low awareness regarding infectious agents, lifestyle, diet and many work exposures. The predictors of the attitude of respondents regarding the preventability of cancer were: believing that cancer has an environmental cause (p=.014), not having a healthy lifestyle (p = 0.004), not smoking waterpipe (p = 0.023), being single (p = 0.013), and having a university degree (p = 0.049). CONCLUSIONS: Efforts should be made to improve awareness of the cancer risk factors regarding infectious agents, lifestyle, diet and many work exposures. This can also be followed by further studies assessing the impact of these community and governmental cancer prevention initiatives on cancer risk factors level of awareness.

Evaluation of risk factors and drug adherence in the occurrence of stroke in patients with atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) patients are at high risk of developing a stroke and anticoagulant medications are generally prescribed to prevent stroke in AF population. OBJECTIVE: This study aims to evaluate stroke risk factors among hospitalized patients with AF and to assess the level of adherence to medications in AF patients and their relation with stroke. METHODS: This is a case-control study conducted between June 1st, 2018 and December 31th, 2018 among AF patients admitted to seven tertiary Lebanese hospitals. Data were collected using a standardized questionnaire. Adherence to medications was assessed using the Lebanese Medication Adherence Scale-14. Odds ratios (OR) expressed the strength of association between the independent variables and the dependent variable and were estimated using unconditional logistic regression adjusted for confounding factors. P<0.05 determined statistical significance. RESULTS: In total, 174 cases of AF patients were included with 87 cases and 87 controls. The risk of stroke among AF significantly increased with the presence of a history of hypertension, aOR 16.04 (95%CI, 2.27-113.37; p=0.005), history of coronary heart disease/myocardial infarction, and history of obesity. Anticoagulant medication significantly decreased the risk of stroke among AF patients, aOR 0.27 (95%CI, 0.07-0.98; P=0.047). High adherence to medications was significantly associated with a reduced risk of stroke, aOR 0.04 (95%CI, 0.01-0.23; p<0.001). CONCLUSIONS: Having a history of hypertension is one of the strongest risk factors for stroke among AF patients in Lebanon. While anticoagulant medication use was associated with a reduced risk for stroke, high adherence to medications is critical for stroke prevention. Public health interventions are needed to tackle low-adherence to medication and prevent stroke among AF patients.

Validation of the Arabic Version of the Minnesota Living with Heart Failure Questionnaire.

BACKGROUND: The Minnesota Living with Heart Failure Questionnaire (MLHFQ) is commonly used to measure quality of life (QOL) in patients with heart failure (HF). We examined the psychometric properties and cultural validity of an Arabic version of the MLHFQ. METHODS: An observational cross-sectional study was conducted with 210 adult HF outpatients. Patients were interviewed with the Arabic MLHFQ and the Patient Health Questionnaire (PHQ-9). Cronbach's alpha coefficient and confirmatory factor analysis were conducted. Patients with different NYHA classes and HF-hospitalization histories were compared on QOL to test known-group validity. RESULTS: The confirmatory factor analysis yielded 3 factors: physical, emotional, and social. Three items (4, 8, and 15) had low loadings. The overall Cronbach's alpha coefficient was 0.92. There were significant differences in MLHFQ by PHQ-9 categories, NYHA class, and HF-hospitalization history. CONCLUSIONS: This Arabic version of MLHFQ is valid and reliable and can be used in Arabic-speaking Lebanese HF populations.