Factors associated with emergency department avoidance during the COVID-19 pandemic and alternatives sought: a cross-sectional, telephone-based survey of frequent emergency department users in Beirut, Lebanon.

OBJECTIVES: To explore avoidant behaviour of frequent emergency department (ED) users, reasons behind ED avoidance and healthcare-seeking behaviours in avoiders during the COVID-19 pandemic. DESIGN AND SETTING: Cross-sectional, telephone-based survey administered between March and August 2021 at a tertiary care centre in Beirut, Lebanon. PARTICIPANTS: Frequent ED users (defined as patients who visited the ED at least four times during the year prior to the first COVID-19 case in Lebanon). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was ED avoidance among frequent ED users. Secondary outcomes included reasons behind ED avoidance and healthcare-seeking behaviours in avoiders. RESULTS: The study response rate was 62.6% and 286 adult patients were included in the final analysis. Within this sample, 45% (128/286) of the patients reported avoidant behaviour. Male patients were less likely to avoid ED visits than female patients (adjusted OR (aOR), 0.53; 95% CI 0.312 to 0.887). Other independent variables associated with ED avoidance included university education (aOR, 1.76; 95% CI 1.004 to 3.084), concern about contracting COVID-19 during an ED visit (aOR, 1.31; 95% CI 1.199 to 1.435) and underlying lung disease (aOR, 3.39; 95% CI 1.134 to 10.122). The majority of the patients who experienced acute complaints and avoided the ED completely (n=56) cited fear of contracting COVID-19 as the main reason (89.3% (50/56)). Most of the ED avoiders (83.9% (47/56)) adopted alternatives for seeking acute medical care, including messaging/calling a doctor (46.4% (26/56)), visiting a clinic (25.0% (14/56)), or arranging for a home visit (17.9% (10/56)). Of the avoiders, 64.3% (36/56) believed that the alternatives did not impact the quality of care, while 30.4% (17/56) reported worse quality of care. CONCLUSIONS: Among frequent ED users, ED avoidance during COVID-19 was common, especially among women, those with lung disease, those with university-level education and those who reported fear of contracting COVID-19 in the ED. While some patients resorted to alternative care routes, telemedicine was still underused in our setting. Developing strategies to reduce ED avoidance, especially in at-risk groups, may be warranted during pandemics.

Prescribing antibiotics in adults with respiratory tract infections in Lebanon.

INTRODUCTION: Antibiotic resistance is a global concern that has significant health and economic burden. The inappropriate use of antibiotics is a major cause of antibiotic resistance; this includes both unnecessary and incorrect prescriptions. Most antibiotics are prescribed in primary care, mainly for respiratory tract infections. This study examines the prescribing practices of physicians for respiratory tract infections in ambulatory settings in Lebanon. METHODS: The study was a cross-sectional review of prescriptions given to a group of employees working in two companies in Greater Beirut in Lebanon (n = 469) between September 2017 and March 2018. Prescriptions and related medical reports were reviewed. Data on the type of infection and the employees' demographics were collected. Antibiotic treatment was considered appropriate based on its adherence to international scientific societies' recommendations and clinical guidelines, including those of the Infectious Diseases Society of America. RESULTS: A total of 372 medical reports and prescriptions were reviewed; 88.2% of these prescriptions included antibiotics. The rate of antibiotic treatment was 82.0% for a diagnosis of flu-like symptoms and 94.6% for acute pharyngitis, of which 34.5% included third generation cephalosporins and fluoroquinolones. Around 93.7% of patients with acute bronchitis without pneumonia received antibiotics, mostly broad-spectrum ones. A significant association was found between the specialty of the prescribing physicians and some types of upper respiratory tract infections. CONCLUSION: This study reveals a high prevalence of inappropriate antibiotic prescribing for respiratory tract infections in the Lebanese ambulatory practice, contributing to the emergence of antimicrobial resistance in the country. It calls for urgent multifaceted interventions to limit unnecessary use and promote antibiotic stewardship.

Patterns and Predictors of Firearm-related Spinal Cord Injuries in Adult Trauma Patients.

INTRODUCTION: Firearm-related spinal cord injuries are commonly missed in the initial assessment as they are often obscured by concomitant injuries and emergent trauma management. These injuries, however, have a significant health and financial impact. The objective of this study was to examine firearm-related spinal cord injuries and identify predictors of presence of such injuries in adult trauma patients. METHODS: This retrospective cohort study examined adult trauma patients (≥16 years) with injuries from firearms included in the 2015 United States National Trauma Data Bank. We performed descriptive and bivariate analyses and compared two groups: patients with no spinal cord injury (SCI) or vertebral column injury (VCI); and patients with SCI and/or VCI. Predictors of SCI and/or VCI in patients with firearm-related injuries were identified using a multivariate logistic regression analysis. RESULTS: There were 34,898 patients who sustained a firearm-induced injury. SCI and/or VCI were present in 2768 (7.9%) patients. Patients with SCI and/or VCI had more frequently severe injuries, higher Injury Severity Score (ISS), lower mean systolic blood pressure, and lower Glasgow Coma Scale (GCS). The mortality rate was not significantly different between the two groups (14.7%, N = 407 in SCI and/or VCI vs 15.0%, N = 4,811 in no SCI or VCI group). Significant general positive predictors of presence of SCI and/or VCI were as follows: university hospital; assault; public or unspecified location of injury; drug use; air medical transport; and Medicaid coverage. Significant clinical positive predictors included fractures, torso injuries, blood vessel or internal organ injuries, open wounds, mild (13-15) and moderate GCS scores (9 - 12), and ISS ≥ 16. CONCLUSION: Firearm-induced SCI and/or VCI injuries have a high burden on affected victims. The identified predictors for the presence of SCI and/or VCI injuries can help with early detection, avoiding management delays, and improving outcomes. Further studies defining the impact of each predictor are needed.

The Weekend Effect in Septic Shock Patients Using the Nationwide Emergency Department Sample Database.

BACKGROUND: The weekend effect is the increased mortality in hospitalized patients admitted on the weekend. The aim of this study was to examine the effect of weekend admissions on septic shock patients. METHODS: This is a retrospective observational study of the 2014 Nationwide Emergency Department Sample Database. Septic shock patients were included in this study using ICD-9-CM codes. Descriptive analysis was done, in addition to bivariate analysis to compare variables based on admission day. Multivariate analysis was conducted to examine the association between admission day and mortality in septic shock patients after adjusting for potential confounding factors. RESULTS: A total of 364,604 septic shock patients were included in this study. The average age was 67.19 years, and 51.1% were males. 73.0% of patients presented on weekdays. 32.3% of septic shock patients died during their hospital stay. After adjusting for confounders, there was no significant difference in the emergency department or in-hospital mortality of septic shock patients admitted on the weekend compared with those admitted during weekdays, (OR = 1.00 [95% CI: 0.97-1.03], P value = 0.985). CONCLUSION: There was no statistically significant difference in overall mortality between septic shock patients admitted on the weekend or weekday. Our results are contradictory to previous studies showing an increased mortality with the weekend effect. The previous observations that have been made may not stand up with current treatment protocols.

The impact of COVID-19 lockdown measures on ED visits in Lebanon.

INTRODUCTION: As the COVID-19 pandemic spread globally, emergency departments (ED) around the world began to report significant drops in volumes and changes in disease patterns. During the early COVID-19 period, Lebanon followed an aggressive containment approach to halt the spread of the disease. OBJECTIVE: This study aims to examine the impact of the different national containment measures and the early COVID-19 outbreak in Lebanon on ED visit volume and disease spectrum in a single center ED in Lebanon. METHODS: This study is a secondary analysis of ED visit administrative data, comparing ED visits during the three months period prior to the first identified COVID-19 case in Lebanon with the first 3 months post-COVID-19. A time series analysis of ED visit trends in relation to the major lockdown measures was conducted. Statistical analyses were performed using the Statistical Package for Social Sciences (SPSS, version 27) and STATA version 15 (StataCorp LLC., College Station,TX). Statistical significance was set at 0.05. RESULTS: The daily ED visit volume significantly decreased in response to the closure of educational institutions (19.96% per day, p-value = 0.04) and the declaration of public mobilization state with border closure (97.11% per day, p-value <0.0001). ED visits decreased by 47.2% post-COVID-19. The drop was highest amongst pediatric patients (66.64%). Patients who presented post-COVID-19, compared to pre-COVID-19 were older (40.39 ± 24.96 vs 33.71 ± 24.83, p-value <0.0001), had higher hospital admission rates (28.8% vs. 22.1%, p-value <0.0001), higher critical care admission rates (5.6% vs. 3.5%, p-value <0.001), and double mortality rate (0.4% vs 0.2%, p-value = 0.006). While visits for most diseases dropped, the odds of presenting to the ED post-COVID19 were higher for bacterial infections and non-communicable disease and lower for injuries and communicable diseases. CONCLUSION: ED visits dropped significantly during the COVID-19 containment period. Understanding the trends of changes in disease entities is important for ED staffing purposes during the pandemic and the varying containment efforts. While stringent lockdown measures were associated with drops in ED visits, understanding the reason behind these drops, specifically whether behavioral or related to true drops in disease prevalence, needs further exploration.

Psychological distress and coping strategies in parents of children with cancer in Lebanon.

OBJECTIVES: To determine the prevalence of psychological distress (PD) among parents of Lebanese children with cancer and to investigate the associated stressors and coping strategies. METHODS: A cross-sectional study conducted at the American University of Beirut Medical Center-Children Cancer Center of Lebanon in 2012. Parents of all children with cancer admitted for treatment were eligible participants. The General Health Questionnaire (GHQ-12) was used to estimate the prevalence of PD. Coping strategies were measured via the Coping Health Inventory for Parents (CHIP). Bivariate and multiple regression analyses were conducted to evaluate the relationship between GHQ-12 (scores 0-36), stressors, family/social support, and coping strategies. RESULTS: One hundred fourteen parents (68.2%) completed the anonymous questionnaire. Based on GHQ-12, significant PD was considered among 56.0% of the parents. It was found to be significantly positively associated with the degree of family financial problems and significantly negatively associated with the child's disease duration. A significant negative relationship was also found between PD and Coping (CHIP) scale, coping pattern I (Maintaining Family Integration and an Optimistic Outlook for the Situation), pattern II (Seeking Social Support), yet not with pattern III (Seeking Information). CONCLUSIONS: PD is prevalent among parents of Lebanese children hospitalized because of cancer. Screening for PD in the latter population is feasible, would identify those who are at risk for disruptive PD, and facilitate the provision of support towards better adjustment and coping. Alleviating parental PD may facilitate the realization of optimal health outcomes.

Opportunities and barriers to enhance research capacity and outputs among academic family physicians in the Arab world.

AIM: To explore the current status of academic primary care research in Arab countries and investigate the barriers to its adequate implementation. BACKGROUND: Research is an essential building block that ensures the advancement of the discipline of Family Medicine (FM). FM research thus ought to be contributed to by all family physicians; nevertheless, its development is being hindered worldwide by several challenges. The amount of research conducted by academic academic family physicians and general practitioners is scant. This phenomenon is more pronounced in the Arab countries. METHODS: An online questionnaire was emailed to all academic family physicians practicing in member Arab countries of the World Organization of Family Doctors WONCA-East Mediterranean Region. FINDINGS: Seventy-six out of 139 academic family physicians from eight Arab countries completed the questionnaire. Around 75% reported that they are required to conduct research studies, yet only 46% contributed to at least one publication. While 75% and 52.6% disclosed their interest in participating in a research team and in leading a research team respectively, 64.5% reported being currently involved in research activities. Of all, 56% have attended a research ethics course. Lack of training in research, the unavailability of a healthcare system that is supportive of research, insufficient financial resources, and the unavailability of electronic health records were perceived as major barriers in conducting FM research. CONCLUSION: Although many physicians in Arab academic institutions expressed enthusiasm to conduct research projects, FM research infrastructure remains to be weak. This demonstrates the need for immense efforts from different parties particularly governments and academic institutions.

The effect of various types of patients' reminders on the uptake of pneumococcal vaccine in adults: A randomized controlled trial.

BACKGROUND: Invasive pneumococcal disease is one of the most important vaccine-preventable diseases threatening the adult community due to missed opportunities for vaccination. This study compares the effect of three different types of patient reminder system on adulthood Streptococcus pneumoniae immunization in a primary care setting. METHODS: The study targeted patients aged 40 and older eligible for pneumococcal vaccine, but did not receive it yet (89.5% of 3072 patients) based on their electronic medical records in a family medicine center in Beirut. The sample population was randomized using an automated computer randomization system into six equal groups, receiving short phone calls, short text messaging system (sms-text) or e-mails each with or without patient education. Each group received three identical reminders spaced by a period of four weeks. Documentation of vaccine administration was then added to the longitudinal electronic patient record. The primary outcome was the vaccine administration rate in the clinics. RESULTS: Of the eligible patients due for the pneumococcal 23-polyvalent vaccine, 1380 who had mobile phone numbers and e-mails were randomized into six equal intervention groups. The various reminders increased vaccination rate to 14.9%: 16.5% of the short phone calls group, 7.2% of the sms-text group and 5.7% of the e-mail group took the vaccine. The vaccination rate was independent of the age, associated education message and the predisposing condition. CONCLUSION: Use of electronic text reminders via e-mails and mobile phones seems to be a feasible and sustainable model to increase pneumococcal vaccination rates in a primary care center.

Jellyfish Stings: A Practical Approach.

Jellyfish have a worldwide distribution. Their stings can cause different reactions, ranging from cutaneous, localized, and self-limited to serious systemic or fatal ones, depending on the envenoming species. Several first aid treatments are used to manage such stings but few have evidence behind their use. This review of the literature describes and discusses the different related first aid and treatment recommendations, ending with a summarized practical approach. Further randomized controlled trials in this field are needed.

Diabetes quality of care at a university community in Beirut.

RATIONALE, AIMS AND OBJECTIVES: To assess the quality of diabetes mellitus (DM) care provided by a group of family doctors in Beirut. METHODS: An observational study, conducted at the American University of Beirut Medical Center-Family Medicine Clinics (AUBMC-FMC), examined the electronic health records (EHRs) of the beneficiaries of the Health Insurance Plan at the American University of Beirut (AUB-HIP) who were older than 20 years (n = 9469) in 2009. The eligible population included patients with DM (n = 701). Several provider/patient-directed interventions were introduced in the late 2000s, including a comprehensive EHRs system with point-of-care computer reminders, a provider financial incentive based on an annual performance appraisal ranked against that of the US Healthcare Effectiveness Data and Information Set (HEDIS) Comprehensive Diabetes Care indicators, as well as periodic up-to-date training. RESULTS: Optimal control for HbA1c, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides and blood pressure were found in 58.6%, 51.0%, 22.4%, 53.3% and 60.2% of the population, respectively. 64.1% and 70.0% received screening for diabetic nephropathy and a dilated eye examination, respectively. When benchmarked against the HEDIS Comprehensive Diabetes Care indicators, the AUB-HIP's quality of care was 13% higher than the average of all plans in the United States. Screening for nephropathy, however, did not reach the above benchmark. CONCLUSIONS: Benchmarking served as an important tool in evaluating the current DM care offered and in detecting gaps, yet interventions are recommended for further improvement.

Screening instruments for depression in primary care: a concise review for clinicians.

Depression is prevalent across the life span worldwide. It is a common problem encountered in primary care settings. The World Health Organization recommends the integration of mental health into general health care in order to seal the existing gap between the number of patients who need mental health care and those who actually receive it. Addressing the burden of mental health problems in primary care settings has its limitations, particularly because of the time constraints in busy primary care clinics as well as the inadequate training of staff and physicians in mental health disorders. That is why reliable, brief, and easy to administer depression screening instruments are important in helping physicians identify patients at risk. The 2-item Patient Health Questionnaire (PHQ-2) is a suitable primary screening tool for depression. If positive, other tools should be administered, such as the PHQ-9 in adults, the PHQ-9 or Geriatric Depression Scale-15 in older adults, or the Arroll's help question or the Edinburgh Postnatal Depression Scale in ante- or postpartum women. Patients with positive scores ought to be interviewed more thoroughly. Computerized depression screening instruments that are interfaced or integrated into electronic health records seem to be promising steps toward optimizing diagnosis, treatment, and follow-up. The availability of adequate management and follow-up are ethical requirements for the utilization of any screening instrument for depression.

Insulin therapy attitudes and beliefs of physicians in Middle Eastern Arab countries.

BACKGROUND: Studies assessing attitudes and beliefs of physicians regarding insulin therapy in Arab countries are scant despite the high prevalence of type 2 diabetes mellitus (T2DM). OBJECTIVE: This study examines family physicians' attitudes and beliefs towards insulin therapy in T2DM patients in the East Mediterranean Region of the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians. METHODS: This is a cross-sectional study conducted on 348 family physicians invited via email to fill an anonymous online questionnaire about their attitudes, beliefs and perceived barriers regarding insulin initiation in T2DM patients. RESULTS: One hundred and twenty-two physicians completed the questionnaire. Of the 122 physicians, 73.6% preferred to delay insulin initiation until it is absolutely essential and 59.0% initiated it themselves. The majority agreed that T2DM patients benefit from insulin prior to the development of complications (85.7%) and that patient education is important (99.1%) and uncomplicated (74.7%). Sixty-three per cent expressed reluctance to start insulin mostly because of perceived patients' reluctance. Referral to endocrinologists to initiate insulin therapy was associated with inadequate experience and concern about risks, particularly in elderly patients (backward logistic regression, P < 0.05). Physicians' reluctance to initiate insulin therapy was associated with patients' perception of insulin initiation as a personal failure and threat to the quality of life (backward logistic regression, P < 0.05). CONCLUSIONS: Although family physicians in the Arab world believe in the benefits of insulin therapy, many are reluctant to initiate it themselves. Further studies are needed per country, as well as multiple measures to minimize the physicians' barriers to insulin prescription.

The effect of two types of sms-texts on the uptake of screening mammogram: a randomized controlled trial.

OBJECTIVE: To compare the effect of two different types of short text message service (SMS-text) reminders on the uptake of screening mammogram. METHODS: A randomized controlled trial was conducted in 2010 among females aged between 40 and 75, benefiting from the Health Insurance Plan at the American University of Beirut, whose cell phone numbers were available in their electronic medical records, and who did not do a mammogram in the past 2 years. The sample (n=385) was randomly divided into two subgroups. The first subgroup (n1=192) received a general SMS-text inviting its members to do a mammogram while the second subgroup (n2=193) received an additional informative SMS-text informing them about the benefits of mammogram screening. RESULTS: 30.7% (59) of subgroup 1 and 31.6% (61) of subgroup 2 underwent a mammogram screening test during the 6 months follow up interval post-intervention (Chi-square test, p-value ≥ 0.05). There was no difference between the response rates in the two subgroups. CONCLUSION: A brief invitation SMS-text message for screening mammogram was found to be as effective as a detailed informative one.