Impact of the 4th of August Beirut explosion mass casualty incident on a university hospital microbial Flora.

BACKGROUND: Following the Beirut explosion, our university hospital received at least 350 casualties. Subsequently, infection control standard practices were compromised. Concerns for Multi-Drug Resistant Organisms (MDROs) infections in injured patients and a resulting hospital outbreak were raised. The objectives of the study were to compare the rate of hospital growing MDROs 6 months before and 6 months after the Beirut explosion, to identify emerging microorganisms and to evaluate the change in surgical infection prevention practices. METHODS: This is a retrospective chart review of patients with hospital acquired infections (HAI) admitted to the hospital before and after the Beirut explosion. The study was conducted between February 4, 2020 and January 4, 2021. Excluded patients were those transferred from other hospitals and those with community acquired infections. The primary outcome was to identify the rate of growing MDROs post explosion. The secondary outcomes were identifying antibiotics used for surgical prophylaxis in patients requiring surgeries and patients diagnosed with a HAI. Therefore, patients were divided in three groups. Control group included patients admitted with explosion-related injuries on that same day. Patients admitted and between February 4 and August 4 and diagnosed with HAI were compared to those admitted post August 4 with explosion-related HAI and to patients diagnosed with non-explosion-related HAI between August 4 and January 4, 2021. An estimated rate of 18-22% MDRO was needed to achieve a statistical significance with 80% power and 0.05 α. Pearson Chi square test was used to analyze the primary outcome. RESULTS: A total of 82 patients with 150 cultures were included in this study. Data showed an increase in the rate of MDRO after the explosion with 37.1% of the cultures taken before the explosion and 53.1% after the explosion (p = 0.05). When comparing the types of HAI in both groups, culture sites were significantly different between pre- and post-explosion patients (p = 0.013). However, both groups had similar types of microbes (p = 0.996) with an increase in candida related infections. CONCLUSION: These findings confirmed that the Beirut explosion impact on antimicrobial resistance was similar to combat zone incidence, where an increase in MDROs rate such as Escherichia coli (E.Coli) and Stenotrophomonas maltophilia, in addition to the increase in candida related infections.

Reproductive health of Syrian refugee women in Lebanon: a descriptive analysis of the Sijilli electronic health records database.

BACKGROUND: The Syrian conflict has been responsible for the highest exodus of refugees, with Lebanon hosting the greatest number of refugees per capita, which placed a significant strain on an already overburdened healthcare system. Women are the most vulnerable group in times of conflict and displacement, with sexual and reproductive health and rights often neglected. This study focuses on the obstetric characteristics and pregnancy outcomes of Syrian Refugee (SR) women in Lebanon, in Comparison to their pre-displacement data. METHODS: This study is a secondary analysis of de-identified data from the Sijilli database. The data reported and analyzed were the refugees' socio-demographics, obstetric history, pregnancy outcomes, experienced maternal and neonatal complications, breastfeeding history and duration, and contraception use and types. Data were reported in both frequencies and means/medians. Chi-square test, t-test, and ANOVA tests were used to compare pregnancies in Syria to those that happened in Lebanon. RESULTS: A total of 1065 female records were included in this study, with 634 ever-pregnant women and the total number of pregnancies being 3272. SR women were shown to get pregnant in Lebanon at a younger age compared to cases in Syria. The number of gravidities is equal in women who got pregnant in Syria and those who moved later to Lebanon. The mean spacing between pregnancies has decreased comparing SR women who got pregnant in Syria only versus those who got pregnant in Lebanon only. Among the mixed group, the mean spacing between pregnancies as well as the prevalence of spontaneous abortions significantly increased after displacing to Lebanon. C-section rate was higher among SR women after moving to Lebanon. Also, maternal complications and not breastfeeding have increased after moving to Lebanon. A prior pregnancy was significantly associated with higher contraception use rate. The most common methods of contraception were oral contraceptive pills and intra-uterine devices. CONCLUSION: The C-section deliveries, spontaneous abortions and maternal complications have all increased among SR women after being displaced to Lebanon. While the age at first pregnancy, mean spacing between their pregnancies and breastfeeding rates have decreased after moving to Lebanon. SR women are less likely to use contraceptives after their displacement. It is necessary to address access to reproductive healthcare and antenatal care delivery among displaced refugee women living in informal tented settlements.

Burnout and coping strategies among health system pharmacists in Lebanon: a cross-sectional study.

BACKGROUND: Burnout in health system pharmacists has been studied in several countries. To date, no data exists on burnout among healthsystem pharmacists in Lebanon. This study aimed to determine the prevalance of burnout, identify factors and describe coping strategies related to burnout among healthsystem pharmacists in Lebanon. METHODS: A cross-sectional study utilizing the Maslach Burnout Inventory- Human Services Survey for Medical Personnel (MBI-HSS (MP))was conducted in Lebanon. A convenience sample of hospital pharmacists in Mount Lebanon and Beirut area filled a paper-based survey in person or via a phone interview. Burnout was defined as having an emotional exhaustion score ≥ 27 and/or depersonalization score ≥ 10. To identify factors associated with burnout, the survey also contained questions on socio-demographic characteristics, professional status, hospital characteristics, professional stressors and professional satisfaction. Participants were also asked about their coping strategies. To adjust for potential confounding, a multivariable logistic regression was used to estimate the adjusted odds ratios of factors and coping strategies associated with burnout. The authors also evaluated burnout according to the broader definition, emotional exhaustion score ≥ 27 or depersonalization score ≥ 10 or low personal accomplishment ≤ 33. RESULTS: Of the 153 health system pharmacists who were contacted, 115 filled the survey (response rate of 75.1%). The overall burnout prevalence reported was n = 50 (43.5%) and was largely driven by high emotional exhaustion n = 41(36.9%). Following multivariate logistic regression, seven factors were associated with increased burnout: older age, B.S. in Pharmacy degree, involvement in student training, no involvement in procurement, divided attention at work, overall dissatisfaction with career, dissatisfaction to neutrality with balance between professional and personal life. Low personal accomplishment was noted in n = 55 (49.5%). The main coping strategies identified were holidays, leisure, hobbies, sports activities, and relaxation. There was no association between the coping strategies used and burnout. The prevalence of burnout according to the broader definition was n = 77 (67%). The factors associated with the broader definition of burnout were older age, overall dissatisfaction with career and dissatisfaction with work life balance. CONCLUSION: Approximately n = 50(43.5%)of health system pharmacists in Lebanon may be at risk for burnout. If using broader definitions incorporating all three subscales of the (MBI-HSS (MP)), the prevalence of burnout was n = 77(67%). This study highlights the need to advocate for pratice reforms to improve the low personal acoomplishment and recommends strategies to mitigate burnout. Further research to assess the current prevalence of burnout and evaluate effective interventions in alleviating burnout amongst health system pharmacists is needed.

Impact of social media education on antimicrobial stewardship awareness among pharmacy, medical and nursing students and residents.

BACKGROUND: Antimicrobial resistance has always been an important issue as antimicrobial therapies are becoming less effective due to incorrect use and overuse. Our objective was to evaluate the impact of social media education on spreading antimicrobial stewardship awareness among healthcare students and residents. METHODS: A prospective interventional study was conducted over 5 months, from November 2021 until March 2022. Weekly educational posts on infectious diseases were posted along with pre- and post- quizzes on a designated Facebook page. The primary endpoint of change in knowledge score was assessed using the independent t-test. Expected average pre-training is 2.5 over 5, and the expected average post-training is a minimum of 3.5 over 5 (common standard deviation of 1) for a minimum of 20% improvement that produces an effect size d = 1. Expecting a larger number of respondents on the pre-test than post-test, the ratio N1/N2 was set to 1.5. With the desired power set to 80% and alpha at 5%, sample size was determined as a minimum of 22 (N1) and 14 (N2). All analyses were carried at the 0.05 significance level. RESULTS: In the entry questionnaire, 85.6% (107/125) of participants believed that antibiotics are overused, 26.4% (33/125) confirmed that they overuse antibiotics, and 88.8% (111/125) confirmed the importance of having an antimicrobial stewardship program. 76.8% (96/125) of the participants regularly use social media for educational purposes and only 2.4% sometimes refer to social media as an educational tool. Improvement in knowledge was noted in all pre and post - quizzes except for two quizzes (prostatitis and acute cystitis - 18.4% and 13.2% improvement respectively). In total, there was a significant 36.2% improvement between all pre and post quizzes [min 13.2% and max 52.8% across all quizzes]. CONCLUSION: This intervention demonstrated the importance of social media as a valuable tool to enhance antimicrobial stewardship knowledge among pharmacy, medical and nursing students and residents. Future studies are needed to examine the impact of social media education on behaviors in practice.

Prevalence of depression symptoms and associated sociodemographic and clinical correlates among Syrian refugees in Lebanon.

BACKGROUND: Since the outbreak of the Syrian war in 2011, close to 6 million Syrian refugees have escaped to Syria's neighbouring countries, including Lebanon. Evidence suggests rising levels of mental health disorders among Syrian refugee populations. Yet, to the best of our knowledge, large-scale studies addressing the mental health of adult Syrian refugees in Lebanon are lacking. We examined the prevalence of depression symptoms, which represent a common and debilitating mental health disorder among Syrian refugee populations in Lebanon, along with their sociodemographic and clinical correlates. METHODS: A cross-sectional survey design was conducted as part of a collaborative project-"Sijilli"- led by the Global Health Institute at the American University of Beirut (Beirut, Lebanon) across 4 informal tented settlements for refugees (Beirut, Bekaa, North, South) in Lebanon among adult Syrian refugees (≥18), over a period extending from 2018 to 2020. The survey inquired about participants' sociodemographic and clinical characteristics, and screened participants for symptoms of depression through sequential methodology using the Patient Health Questionnaire (PHQ-2 and PHQ-9). RESULTS: A total of 3255 adult Syrian refugees were enrolled in the study. Of those refugees, 46.73% (n = 1521) screened positive on the PHQ-2 and were therefore eligible to complete the PHQ-9. In the entire sample (n = 3255), the prevalence of moderate to severe depression symptoms (PHQ-2 ≥ 2 and then PHQ-9 ≥ 10) was 22% (n = 706). Further analyses indicate that being ≥45 years of age (OR 1.61, 95% CI 1.13-2.30), a woman (OR 1.34, 95% CI 1.06-1.70), widowed (OR 2.88, 95% CI 1.31-6.32), reporting a neurological (OR 1.73, 95% CI 1.15-2.60) or a mental health condition (OR 3.98, 95% CI 1.76-8.97) are major risk factors for depression. CONCLUSION: Our study suggests that an estimated one in four Syrian refugees in Lebanon shows moderate to severe depression symptoms, and our findings have important public health and clinical implications on refugee health. There is a need to enhance screening efforts, to improve access and referral to mental health services, and to improve post-migration factors among Syrian refugees in Lebanon.

Factors Affecting Implant Stability Quotients at Immediately and Conventionally Loaded Implants in the Posterior Maxilla: A Split-Mouth Randomized Controlled Trial.

PURPOSE: To assess primary and secondary stability of variable-thread tapered implants in the posterior maxilla and analyze the impact of various factors on implant stability quotients (ISQs). MATERIALS AND METHODS: Twenty-six subjects received 3-4 adjacent implants in the maxillary premolar-molar sextants to replace bilateral tooth loss. The implants on one side were immediately loaded with a provisional fixed prosthesis regardless of their primary stability. The contralateral control implants were conventionally loaded. Bone quality was subjectively recorded and primary stability was assessed by means of insertion torque values (ITVs) and ISQs in 4 directions. Secondary stability was measured by ISQ at definitive prosthesis delivery (3-3.5 months postoperatively), and 12 months after definitive loading. The impact of measurement direction, loading protocol, time, site-related (bone quality, implant position, crestal buccal bone thickness, apical cortical anchorage), and implant-related (implant dimensions, abutment height) variables on ISQs was assessed. RESULTS: For logistic reasons, ISQs were obtained for only 18 patients with 60 test and 60 control implants. Most of the implants (82%) at baseline had their lowest ISQ on the buccal aspect. There were no significant differences between ISQs measured in the buccal and palatal directions, or between ISQs in the mesial and distal directions. The mean of buccal and palatal ISQs was significantly lower than the mean of the 2 interproximal measurements at all evaluation periods. ISQs were not significantly different between the 2 loading groups at any time point. All implants showed a time-dependent increase in ISQs. Baseline ISQ correlated weakly with bone quality and ITV. None of the variables had a significant impact on baseline ISQs, except for implants in second molar sites which showed poorer primary stability than first premolars. CONCLUSION: Measurement direction and time are the most significant parameters affecting ISQs of variable-thread tapered implants in the posterior maxilla.

mHealth use for non-communicable diseases care in primary health: patients' perspective from rural settings and refugee camps.

Background: Non-communicable diseases (NCDs) account for 85% of deaths in Lebanon and contribute to remarkable morbidity and mortality among refugees and underserved populations. This study assesses the perspectives of individuals with hypertension and/or diabetes in rural areas and Palestinian refugee camps towards a population based mHealth intervention called 'eSahha'. Methods: The study employs a mixed-methods design to evaluate the effectiveness of SMSs on self-reported perceptions of lifestyle modifications. Quantitative data was collected through phone surveys, and qualitative data through focus group discussions. Descriptive statistics and bivariate analysis were performed. Results: About 93.9% (n = 1000) of respondents perceived the SMSs as useful and easy to read and understand. About 76.9% reported compliance with SMSs through daily behavioral modifications. Women (P = 0.007), people aged ≥76 years (P < 0.001), unemployed individuals (P < 0.001), individuals who only read and write (P < 0.001) or those who are illiterate (P < 0.001) were significantly more likely to receive and not read the SMSs. Behavior change across settings was statistically significant (P < 0.001). Conclusion: While SMS-based interventions targeting individuals with hypertension and/or diabetes were generally satisfactory among those living in rural areas and Palestinian refugee camps in Lebanon, a more tailored approach for older, illiterate and unemployed individuals is needed. Keywords: e-health, refugees.

Use of over the counter products in older cardiovascular patients admitted to a tertiary care center in USA.

BACKGROUND: In recent years there has been a substantial increase in the use of over-the-counter (OTC) products around the world. While they are assumed to be safe by consumers, they can potentially lead to adverse effects and drug interactions particularly in older adults. METHODS: We assessed the patterns of OTC products used by older adults admitted to the cardiology service in a tertiary care medical center in the USA over a three month period. We conducted a retrospective chart review where older adults with cardiovascular diseases (CVD) who were taking at least one OTC product at home were included. RESULTS: Out of 404 patients who were admitted to the cardiology service, 281 (69.6%) were taking OTC products. Patients were taking a total of 659 OTC products; mean of 2.35 ± 1.57 and the range varied from 1 to 9 products. The most commonly used products were vitamins (37.3%), followed by laxatives (17%), minerals (13.6%), stomach acid reducers (9%), and analgesics (3.6%). OTC users were found to be suffering from more comorbidities and received more prescription medications as compared to non-users. Gender and age did not have an impact on the use of OTC products while patients with atrial fibrillation, sleep apnea and gastro-esophageal reflux disease were more likely to use OTC products. CONCLUSION: Use of OTC products is quite frequent in older adults with CVD in our study. Clinicians should ask about OTC product usage and counsel patients about the risks and benefits associated with their use.

Potentially inappropriate home medications among older patients with cardiovascular disease admitted to a cardiology service in USA.

BACKGROUND: The use of potentially inappropriate medications (PIMs) may pose more risks than benefits to patients and is a major factor contributing to the likelihood of serious adverse drug reactions and negative health outcomes among older patients. METHODS: A retrospective chart review was conducted in a tertiary care center in USA where home medications of the older patients were reviewed and analyzed upon hospital admission over three months, from March till May 2016. Inclusion criteria were age of 65 years and above, history of cardiovascular disease, and admission to the cardiology service. The aim of our study was to determine the frequency and factors associated with PIMs, by applying the updated Beers 2015 criteria. RESULTS: A total of 404 patients were included in the study and were taking a total of 4669 medications at home, an average of 11.6 ± 4.5 medications per patient. The proportion of PIMS was 20% of all medications reported, with an average of 2.4 PIM per patient, and 87.4% of patients were receiving at least one PIM. Significant association was found between use of PIMs and number of home medications, female gender, and number and types of comorbidities. Comorbidities associated with more PIMs were heart failure, atrial fibrillation/flutter, history of falls/fractures, cerebrovascular accident, and depression. The most commonly prescribed PIMs were: drugs that may exacerbate or cause syndrome of inappropriate antidiuretic hormone secretion or hyponatremia (29.7%), scheduled use of proton pump inhibitors (PPIs) > 8 weeks in non-high-risk patients (11.3%), and benzodiazepines (8.1%). CONCLUSIONS: A high prevalence of PIMs in older patients with cardiovascular disease was observed. Provider education and detailed assessment of medication lists upon hospital admission by multidisciplinary teams can help in preventing the use of PIMs.

Distribution and predictors of emergency department charges: the case of a tertiary hospital in Lebanon.

BACKGROUND: As health care costs continue to increase worldwide, health care systems, and more specifically hospitals are facing continuous pressure to operate more efficiently. One service within the hospital sector whose cost structure has been modestly investigated is the Emergency Department (ED). The study aims to report on the distribution of ED resource use, as expressed in charges, and to determine predictors of/contributors to total ED charges at a major tertiary hospital in Lebanon. METHODS: The study used data extracted from the ED discharge database for visits between July 31, 2012 and July 31, 2014. Patient visit bills were reported under six major categories: solutions, pharmacy, laboratory, physicians, facility, and radiology. Characteristics of ED visits were summarized according to patient gender, age, acuity score, and disposition. Univariate and multivariate analyses were conducted with total charges as the dependent variable. RESULTS: Findings revealed that the professional fee (40.9 %) followed by facility fee (26.1 %) accounted for the majority of the ED charges. While greater than 80 % of visit charges went to physician and facility fee for low acuity cases, these contributed to only 52 and 54 % of the high acuity presentations where ancillary services and solutions' contribution to the total charges increased. The total charges for males were $14 higher than females; age was a predictor of higher charges with total charges of patients greater than 60 years of age being around $113 higher than ages 0-18 after controlling for all other variables. CONCLUSION: Understanding the components and determinants of ED charges is essential to developing cost-containment interventions. Institutional modeling of charging patterns can be used to offer price estimates to ED patients who request this information and ultimately help create market competition to drive down costs.

Cafeteria diet-fed mice is a pertinent model of obesity-induced organ damage: a potential role of inflammation.

OBJECTIVE: This study is aimed at evaluating the effects of a cafeteria diet (obesity) mouse model on early multi-organ functional, structural, endocrine and biochemical alterations. MATERIALS AND METHODS: Multi-organ damage is assessed using clinical, biochemical, pathological, and inflammatory parameters in 30 mice fed one of the three diets for 15 weeks: standard chow diet (SC), high fat (HF), or "Cafeteria diet" (CAF) (standard SC and a choice of highly palatable human cafeteria foods: chocolate, biscuits, and peanut butter). RESULTS: CAF diet was associated with an increase in body weight, energy intake, and serum cholesterol levels compared to the other diets, as well as higher insulin levels and lower glucose tolerance. Additionally, consumption of the CAF diet was associated with significantly higher weight gain, abdominal fat, and serum IL-6 levels, as well as more damage in the heart (coronary perivascular fibrosis and steatosis), kidney (chronic interstitial inflammation and glomerular sclerosis), and liver (liver weight, portal fibrosis, apoptosis, and steatosis) compared to the HF diet. CONCLUSION: Functional and structural damage in CAF were higher than HF of similar macronutrient composition. This study provides a novel dietary model in mice that mimics multi-organ physiologic alterations in humans secondary to obesity.

Validation of an Arabic version of the GHQ-28 against the Beck depression inventory for screening for depression in war-exposed civilians.

This study estimates the psychometric properties of the Arabic GHQ-28 against the BDI-II for screening for depression in war-exposed civilians. Two data sets collected in a civilian sample from South Lebanon were analyzed. Internal consistency in the two samples was high for the GHQ-28 (0.91 and 0.80) and the BDI-II (0.88 and 0.84). The BDI-II was significantly correlated with the GHQ-28 total score and the Depression subscale. The GHQ-28 yielded similar findings for depression cut-off scores compared to the BDI-II: for the GHQ-28 total score, a cut-off at 5/6 is recommended for detecting "severe/moderate" depression, and 8/9 for "severe" only, while from the Depression subscale analysis the recommendation was to use 8/9 as a cutoff for "severe/moderate" and 9/10 for "severe" depression. The Arabic GHQ-28 was found to be a valid instrument for screening for depression in the studied population.

Outcome of depression and anxiety after war: a prospective epidemiologic study of children and adolescents.

Prospective studies of children exposed to war have not investigated disorders other than posttraumatic stress disorder (PTSD) and have methodological limitations. From a stratified random sample of 386 children and adolescents who had been interviewed 3 weeks after war exposure (Phase 1) a random subsample (N = 143) was interviewed a year later (Phase 2). PTSD, major depressive disorder (MDD), separation anxiety disorder (SAD), overanxious disorder (OAD), and psychosocial stressors were assessed using structured interviews administered to both children and adolescents and their parents. The prevalence of disorders among the 143 at Phase 1 was MDD 25.9%, SAD 16.1%, OAD 28.0%, and PTSD 26.0%, with 44.1% having any disorder. At Phase 2 the prevalence was MDD, 5.6%; SAD, 4.2%; OAD, 0%; and PTSD, 1.4%, with 9.2% having any disorder. Occurrence of disorders at Phase 1 was associated with older age, prewar disorders, financial problems, fear of being beaten, and witnessing any war event (ORs ranged from 2.5 to 28.6). Persistence of disorders to Phase 2 was associated with prewar disorders (OR = 6.0) and witnessing any war event (OR = 14.3). There are implications for detection of at-risk cases following wars by screening for adolescents exposed to family violence, those with prewar disorders, and those who directly witnessed war events to target them for specific interventions.

Dietary patterns in cardiovascular diseases prevention and management: review of the evidence and recommendations for primary care physicians in Lebanon.

The objective of this paper is to discuss the advantages of using the dietary pattern approach in evaluating the role of diet in cardiovascular diseases (CVD) prevention and management and to report on the association between major dietary patterns and CVD risk factors among Lebanese adults. The significance of this type of research to primary care physicians is also highlighted. The dietary pattern approach overcomes the inconsistent findings of single nutrient analysis in evaluating diet-disease associations, takes into consideration the synergistic effects of nutrients, and provides culture specific recommendations. Using data from the national Nutrition and Non-Communicable Disease Risk Factor Survey, we appraised the association of dietary patterns with CVD risk factors among Lebanese adults. Two major dietary patterns were identified: Western pattern, characterized by high intake of fast food sandwiches, desserts, and carbonated beverages and the traditional Lebanese pattern, characterized by high intakes of fruits and vegetables, olives and olive oil, and traditional dishes. Only the Western pattern was associated with increased risk of obesity (abdominal obesity), hyperglycemia and the metabolic syndrome. These findings demonstrated the valuable results that can be obtained using the dietary patterns approach in evaluating the association between diet and CVD risk factors and provided evidence that this approach can be used as a tool to push for desirable dietary changes in the country.

Microbial assessment of commercial pet foods marketed in the United Arab Emirates.

Examining the microbiological characteristics of pet food is imperative to safeguard the health and well-being of companion animals, pet owners, and the surrounding environment. Domestic animals, known for carrying harmful microorganisms, pose a significant health risk, especially in close proximity to people and children. Notably, no studies have previously investigated pet food quality in the Gulf Cooperation Council countries, in particular, the United Arab Emirates (UAE). This study examined the microbiological quality of all stock keeping units (SKUs) of pet foods marketed in UAE (n = 118). Parameters assessed include Total Aerobic Microbial Count (TAMC), Enterobacteriaceae, Total Yeast and Mold Count (TYMC), Salmonella, Listeria monocytogenes, and Clostridium species. Among the 118 samples, 33 (28%) exceeded the acceptable TAMC limit of 106 CFU/g, highlighting significant variations based on manufacturers and ingredients. Eight samples (7%) surpassed the maximum Enterobacteriaceae limit of 3 × 102 CFU/g. TYMC levels exhibited variation, with 33 (28%) exceeding the limit of 104 CFU/g. L. monocytogenes was identified in 44 (37%) of the samples, while Salmonella was not detected. Clostridium contamination was observed in 28 (24%) of the samples. Statistical analyses revealed associations between pet food characteristics and microbial quality, underscoring the imperative for international standards to ensure the safety of pet food. These findings carry significant implications for pet owners, regulatory bodies, and the pet food industry, emphasizing the need for ongoing efforts to enhance the overall quality and safety of pet food products.

A national study on nurses' retention in healthcare facilities in underserved areas in Lebanon.

BACKGROUND: Nursing shortages and maldistribution are priority issues for healthcare systems around the globe. Such imbalances are often aggravated in underserved areas, especially in developing countries. Despite the centrality of this issue, there is a dearth of studies that examine the retention of nurses in underserved areas in the Middle East Region. This study investigates the characteristic and the factors associated with the retention of nurses working in rural areas in Lebanon. METHODS: This study uses a non-experimental cross-sectional design to survey nurses working in underserved areas of Lebanon. Underserved areas in Lebanon were identified using WHO definition. A total of 103 health facilities (hospitals and primary healthcare centers) located in these areas were identified and all nurses working at these facilities received a copy of the survey questionnaire. The questionnaire included five sections: demographic, work-life, career plan, job satisfaction, and assessment of work environment. Analysis included univariate and bivariate (chi-square, Student's t-test and ANOVA) tests to describe the respondents and examine the significance between nurses' characteristics and their intent to stay. A logistic regression model was constructed to identify factors associated with nurses' intent to stay in underserved areas. RESULTS: A total of 857 nurses from 63 Primary Healthcare (PHC) centers and hospitals responded to the questionnaire (75.5% response rate). Only 35.1% of nurses indicated their intent to stay in their current job over the coming one to three years. Surveyed nurses were most satisfied with relationship with co-workers and least satisfied with extrinsic rewards. Rural nurses working in PHC centers were more satisfied than their hospital counterparts on all aspects of work and had significantly higher intention to stay (62.5% compared to 31.5% in hospitals, P < 0.001). Regression analysis revealed that nurses less likely to report intent to stay were younger, unmarried, with less years of work experience and were not working towards a higher degree. Analysis reveals a directly proportional relationship between nurses' reported job satisfaction and their intent to stay. CONCLUSION: This study reveals poor retention of nurses in rural and underserved areas in Lebanon, especially in the hospital sector. The status quo is disquieting as it reflects an unstable and dissatisfied nursing workforce. Developing targeted retention strategies for younger nurses and those working in hospitals as well as the offering of professional development opportunities and devising an incentive scheme targeting rural nurses is pivotal to enhance nurses' job satisfaction and retention in rural settings.

Hospital accreditation, reimbursement and case mix: links and insights for contractual systems.

BACKGROUND: Resource consumption is a widely used proxy for severity of illness, and is often measured through a case-mix index (CMI) based on Diagnosis Related Groups (DRGs), which is commonly linked to payment. For countries that do not have DRGs it has been suggested to use CMIs derived from International Classification of Diseases (ICD). Our research objective was to use ICD-derived case-mix to evaluate whether or not the current accreditation-based hospital reimbursement system in Lebanon is appropriate. METHODS: Our study population included medical admissions to 122 hospitals contracted with the Lebanese Ministry of Public Health (MoPH) between June 2011 and May 2012. Applying ICD-derived CMI on principal diagnosis cost (CMI-ICDC) using weighing similar to that used in Medicare DRG CMI, analyses were made by hospital accreditation, ownership and size. We examined two measures of 30-day re-admission rate. Further analysis was done to examine correlation between principal diagnosis CMI and surgical procedure cost CMI (CMI-CPTC), and three proxy measures on surgical complexity, case complexity and surgical proportion. RESULTS: Hospitals belonging to the highest accreditation category had a higher CMI than others, but no difference was found in CMI among the three other categories. Private hospitals had a higher CMI than public hospitals, and those more than 100 beds had a higher CMI than smaller hospitals. Re-admissions rates were higher in accreditation category C hospitals than category D hospitals. CMI-ICDC was fairly correlated with CMI-CPTC, and somehow correlated with the proposed proxies. CONCLUSIONS: Our results indicate that the current link between accreditation and reimbursement rate is not appropriate, and leads to unfairness and inefficiency in the system. Some proxy measures are correlated with case-mix but are not good substitutes for it. Policy implications of our findings propose the necessity for changing the current reimbursement system by including case mix and outcome indicators in addition to accreditation in hospital contracting. Proxies developed may be used to detect miss-use and provider adverse behavior. Research using ICD-derived case mix is limited and our findings may be useful to inform similar initiatives and other limited-setting countries in the region.

Predictors of surgical site infection following reconstructive flap surgery: A multi-institutional analysis of 37,177 patients.

Purpose: Rates of surgical site infection (SSI) following reconstructive flap surgeries (RFS) vary according to flap recipient site, potentially leading to flap failure. This is the largest study to determine predictors of SSI following RFS across recipient sites. Methods: The National Surgical Quality Improvement Program database was queried for patients undergoing any flap procedure from years 2005 to 2020. RFS involving grafts, skin flaps, or flaps with unknown recipient site were excluded. Patients were stratified according to recipient site: breast, trunk, head and neck (H&N), upper and lower extremities (UE&LE). The primary outcome was the incidence of SSI within 30 days following surgery. Descriptive statistics were calculated. Bivariate analysis and multivariate logistic regression were performed to determine predictors of SSI following RFS. Results: 37,177 patients underwent RFS, of whom 7.5% (n = 2,776) developed SSI. A significantly greater proportion of patients who underwent LE (n = 318, 10.7%) and trunk (n = 1,091, 10.4%) reconstruction developed SSI compared to those who underwent breast (n = 1,201, 6.3%), UE (n = 32, 4.4%), and H&N (n = 100, 4.2%) reconstruction (p < .001). Longer operating times were significant predictors of SSI following RFS across all sites. The strongest predictors of SSI were presence of open wound following trunk and H&N reconstruction [adjusted odds ratio (aOR) 95% confidence interval (CI) 1.82 (1.57-2.11) and 1.75 (1.57-1.95)], disseminated cancer following LE reconstruction [aOR (CI) 3.58 (2.324-5.53)], and history of cardiovascular accident or stroke following breast reconstruction [aOR (CI) 16.97 (2.72-105.82)]. Conclusion: Longer operating time was a significant predictor of SSI regardless of reconstruction site. Reducing operating times through proper surgical planning might help mitigate the risk of SSI following RFS. Our findings should be used to guide patient selection, counseling, and surgical planning prior to RFS.

Aflatoxins and Ochratoxin A in Tea Sold in Lebanon: Effects of Type, Packaging, and Origin.

Tea is among the oldest and most-known beverages around the world, and it has many flavors and types. Tea can be easily contaminated in any of its production steps, especially with mycotoxins that are produced particularly in humid and warm environments. This study aims to examine the level of ochratoxin A (OTA) and total aflatoxin (AF) contamination in black and green tea sold in Lebanon, evaluate its safety compared to international standards, and assess the effect of different variables on the levels of OTA and AFs. For this, the Lebanese market was screened and all tea brands (n = 37; 24 black and 13 green) were collected twice. The Enzyme-Linked Immunoassay (ELISA) method was used to determine OTA and AFs in the samples. AFs and OTA were detected in 28 (75.7%) and 31 (88.6%) samples, respectively. The average of AFs in the positive (above detection limit: 1.75 µg/kg) samples was 2.66 ± 0.15 µg/kg, while the average of OTA in the positive (above detection limit: 1.6 µg/kg) samples was 3.74 ± 0.72 µg/kg. The mean AFs in black and green tea were 2.65 ± 0.55 and 2.54 ± 0.40 µg/kg, respectively, while for OTA, the mean levels were 3.67 ± 0.96 and 3.46 ± 1.09 µg/kg in black and green tea samples, respectively. Four brands (10.8%) contained total aflatoxin levels above the EU limit (4 µg/kg). As for OTA, all samples had OTA levels below the Chinese limit (5 µg/kg). No significant association (p > 0.05) was found between OTA and tea type, level of packaging, country of origin, country of packing, and country of distribution. However, AF contamination was significantly (p < 0.05) higher in unpacked tea, and in brands where the country of origin, packing, and distributor was in Asia. The results showed that the tea brands in Lebanon are relatively safe in terms of AFs and OTA.

Evolution of COVID-19 infection characteristics in a Lebanese cohort of inpatients during different pandemic periods.

This study aims to describe COVID-19 patients characteristics, laboratory and imaging results, and the different outcomes of patients admitted to the Lebanese American University Medical Center-Rizk Hospital over a period of 9 months. In this observational retrospective study, data were obtained from electronic medical records of 491 male and female patients from the ages of 17 to 97. Analysis of the patients was performed in 3 periods: August 2020 to October 20 November 202020 to January 2021 and February 2021 to April 2021 corresponding with 3 waves of newly diagnosed cases during this period. The sample showed a male predominance with an average age of 63. The average hospitalization length was 10.1 days. The majority of patients were discharged to quarantine. The distribution of hospitalized cases was significantly correlated to the monthly distribution of newly COVID-19 cases in Lebanon. There was no significant difference in patient's characteristics between the 3 periods of the study (gender, age, body mass index, smoking, and medical conditions). Clinical presentations of the patients varied between the 3 periods. Similarly, the course and outcome of infection varied. Patients received less oxygen during period 1, while more patients were cured during period 3. This study presents the first Lebanese cohort of COVID-19 patients with their medical background, clinical presentation, laboratory results, radiological findings and course of infection with its outcome. It also shows how the relations between the medical manifestation of the COVID-19 pandemic and the socio-political measures of infection control are deeply intertwined.