Exodus of Lebanese doctors in times of crisis: a qualitative study.

Introduction: Since 2019, Lebanon is experiencing an unprecedented exodus of doctors, seriously threatening the national health system, which is expected to continue without quick and effective solutions. Therefore, this study aimed to understand the factors that push Lebanese doctors to migrate and the factors that retain others in the country. Additionally, this study aims to propose solutions to preserve an adequate supply of medical care amidst the crisis. Methods: Qualitative semi-structured interviews and focus group discussions were conducted using pre-developed guides. Purposive and snowball sampling was adopted to recruit physicians who emigrated and physicians staying in Lebanon. Transcripts of interviews and focus groups were coded using Dedoose software and analyzed through a combination of inductive and deductive approaches. Results: Emigration was found to be the result of numerous interconnected factors. The main drivers for emigration were declining income, career problems, reduced quality of care, unhealthy work environment, and the deteriorated political and socio-economic contexts leading to instability and insecurity. As for the retention factors, they included affective attachment and sense of belonging to the professional environment and the country, followed by recognition and valorization at work. Several recommendations were developed to maintain quality of care delivery, including reforms of the health system, development of focused human resource retention strategies based on resource mapping evidence, negotiations with recruiting institutions to endorse the code ethics ending unethical practices draining countries' human resources, provision of financial incentives to doctors, and the recognition and valorization of physicians. Other rapid interventions were suggested, such as short-term medical missions to mitigate shortages in certain specialties, telemedicine, adaptation of recruitment processes to compensate for resources shortages in certain specialties, and adoption of task-shifting approaches to alleviate the workload on overburdened specialists. Discussion: The findings of this study shed the light on the different factors influencing migration while framing them in the Lebanese context. These findings and recommendations should inform stakeholders and policy makers about the interventions needed to restore the quality of care. The feasibility and sustainability of most formulated recommendations depend on several factors, with political and socio-economic security and stability being the most crucial ones.

Genetic Polymorphisms Involved in Bladder Cancer: A Global Review.

Bladder cancer (BC) has been associated with genetic susceptibility. Single peptide polymorphisms (SNPs) can modulate BC susceptibility. A literature search was performed covering the period between January 2000 and October 2020. Overall, 334 articles were selected, reporting 455 SNPs located in 244 genes. The selected 455 SNPs were further investigated. All SNPs that were associated with smoking and environmental exposure were excluded from this study. A total of 197 genes and 343 SNPs were found to be associated with BC, among which 177 genes and 291 SNPs had congruent results across all available studies. These genes and SNPs were classified into eight different categories according to their function.

Neoadjuvant Chemotherapy for Muscle-invasive Bladder Cancer in a Lebanese experience: in all aspects.

BACKGROUND: Bladder cancer (BC) is the most common malignant tumor of the urinary tract and the 11th most frequent cancer worldwide. BC is the 2nd most common cancer in Lebanon in men and women. MATERIALS AND METHODS: After searching for patients records in the pathology and oncology database, we identified those who underwent a cystectomy between 2017 and 2019 in our hospital, Hotel Dieu de France - Beirut. We selected for the study the patients who have undergone a cystectomy for MIBC. We excluded patients who initially had a pelvic tumor, or a prostate cancer invading the bladder, and patients with absent medical record from the study. We also noted the gender of the patients, if they are smokers and the number of pack years at the time of diagnosis, as well as their age, the histological type of the tumor, its stage according to the TNM classification and its grade. We also noted whether neoadjuvant chemotherapy was taken by the study 's subjects. RESULTS: The total number of patients who met the inclusion and exclusion criteria was 38. The median age of the population was 66 (± 10) years and the median number of pack years at diagnosis was 60 (± 36). 79% of study 's patients were males and 21% were females. Regarding the tumor 's histological type, the urothelial type predominated with 92% while the remaining 8% were of the squamous type. Regarding treatment modalities, only 20% of patients in the study received neoadjuvant chemotherapy before cystectomy. 80% of patients underwent a cystectomy directly without neoadjuvant and/or adjuvant chemotherapy. No patient received adjuvant chemotherapy. Among the 7 patients, 2 patients (29%) presented a pathological complete response (pCR; equivalent to pT0N0M0). 14% had a pT3 stage post-neoadjuvant chemotherapy and 43% had a pT4 stage. DISCUSSION AND CONCLUSIONS: We can note a reluctance of urologists at our institution to prescribe neoadjuvant chemotherapy. It would therefore be interesting to extend the study to the national level with a larger number of patients, as well as to evaluate survival in patients who received neoadjuvant chemotherapy, especially in those presenting a pCR. Our study can serve as a point of change in the practice of urologists in Lebanon regarding BC.

Novel breakthroughs in advanced prostate cancer management.

INTRODUCTION: Although PSA screening has been rationalized, prostate cancer continues to have the highest incidence rate in 2021, and alone accounts for 26% of cancer diagnoses in men. A thorough review of the medical literature highlights a vast array of approved and investigational treatments for prostate cancer. Thus, selecting the best treatment option for the appropriate patient at the right time is crucial. Hence, biomarkers help in defining optimal patient stratification, revealing potential processes through which a drug might exert its impact and aid in the tailoring of treatments for efficient personalized medicine. AREAS COVERED: This article is a pragmatic review of novel prostate cancer therapies that can help guide clinicians in tackling prostate cancer with the latest treatments. EXPERT OPINION: Local radiotherapy has proven to be a game changer for low burden, de novo metastatic prostate cancer. Androgen deprivation therapy continues to be the ultimate treatment. Delaying resistance to these agents will undoubtedly be a breakthrough in the treatment of prostate cancer. When it comes to metastatic castrate-resistant disease, treatment options become narrower. PARP inhibitors and N-terminal domain inhibitors offer new hope and have a synergistic effect, with immunotherapy adding promising agents to the therapeutic arsenal.

Genetic susceptibility of bladder cancer in the Lebanese population.

BACKGROUND: Bladder cancer (BC) is the 10th most frequent tumor worldwide. Evidence shows an association between elevated risk of BC and various single nucleotide polymorphisms (SNP). BC incidence was the highest in Lebanon according to Globocan 2018 report, but little is known about the genetic susceptibility of Lebanese people to this disease. We aim to evaluate whether this prominent incidence of BC in Lebanon is attributable to known coding genetic variants. METHODS: A case-control study was conducted at Hotel-Dieu de France Hospital, Beirut. A cohort of 51 Lebanese patients with BC were recruited between 2017 and 2020. Whole Exome Sequencing (WES) was performed on peripheral blood samples to detect coding genetic variants in the patients. An in-house database including WES data from 472 Lebanese individuals served as control. Literature review of the genetic predisposition to BC was conducted to establish a database of variants known to influence the risk of BC. In-common SNPs were identified between cases and the aforecited database, and their allelic frequencies was quantified in the former and in controls. Comparative analysis of the allelic frequencies of each in-common SNP was carried out between cases, controls, and the genome aggregation database (gnomAD). Analysis was performed by applying the binomial law and setting the p-value to 10- 10. RESULTS: 484 polymorphisms associated with BC were extracted from the literature review ;151 of which were in-common with the 206 939 variations detected by WES in our cases. Statistically significant differences (p-value < 10- 10) in allelic frequencies was seen in 11 of the 151 in-common SNPs, but none of which corresponds with a higher BC risk. Moreover, rs4986782 variant in the NAT1 gene is not associated with BC in the Lebanese population. `. CONCLUSION: This is the first next-generation sequencing (NGS)- based study investigating BC risk in a Lebanese cohort of 51 patients. The majority of known exonic variants in the literature were not associated with BC in our patients. Further studies with larger sample sizes are warranted to explore the association of BC in our population with known non-coding genetic variants, and the remainder of WES-generated private Lebanese variants.

Decontextualisation for framing effect reduction.

BACKGROUND: The aim of this study is to demonstrate the presence of a framing effect that influences residents' decision-making and to assess decontextualisation as an intervention strategy to reduce the influence of framing on their decision. METHODS: This is a randomised controlled trial in which researchers sent an evaluation questionnaire to all residents of … University including clinical vignettes, with questions formulated in two different ways on the same subject and a decontextualisation test involving logical reasoning problems. The researchers then sent to all participants different clinical vignettes evaluating the same dimensions as those addressed in the previous part. RESULTS: The response rate was 86 (28.2%), of which they included 52 (60.4%) in the analysis. The framing effect was present in 37 (71.1%) of responses and then decreased to 35 (67.3%) after the decontextualisation test, especially at the level of the type of framing involving risky decision-making (p = 0.03). DISCUSSION: Decontextualisation is an effective strategy for reducing bias related to the framing effect among residents, particularly the type of framing involving risky decision-making. In medical teaching, decontextualisation exercises may help improve critical thinking and reduce the framing effect.

Determinants of pyelonephritis onset in patients with obstructive urolithiasis.

BACKGROUND: Acute obstructive pyelonephritis due to urolithiasis represents a medico-surgical emergency that can lead to life-threatening complications. There are still no established factors that reliably predict progression toward acute pyelonephritis in patients presenting with a simple renal colic. OBJECTIVE: To investigate clinical and paraclinical factors that are associated with the onset of acute obstructive pyelonephritis. METHODS: Patients presenting to the emergency department for renal colic with obstructive urolithiasis on imaging were enrolled in the study. Demographic data, vital signs, medical comorbidities, blood test results, urinalysis, and radiological findings were recorded. Obstructive pyelonephritis was defined by the presence of two or more of the following criteria: fever, flank pain or costovertebral angle tenderness, and a positive urine culture. RESULTS: Seventeen patients out of 120 presenting with renal colic, were diagnosed with acute obstructive pyelonephritis (14%). Parameters that were associated with the onset of obstructive pyelonephritis were: diabetes (p = 0.03), elevated CRP (p = 0.01), stone size (>5 mm) (p = 0.03), dilatation of renal pelvis (p = 0.01), peri-renal fat stranding (p = 0.02), and positive nitrites on urinalysis (p < 0.01). Hyperleukocytosis, acute kidney injury, multiple stones, pyuria (>10/mm3), hypertension, and were not associated with the onset of obstructive pyelonephritis. CONCLUSION: This study showed that known diabetic status, elevated CRP, positive urine nitrites, stone size (>5 mm), pyelic dilatation, and peri-renal fat stranding were associated with the onset of pyelonephritis in patients presenting to the emergency department with obstructive urolithiasis.

Urothelial carcinoma in COVID-19: lessons from a pandemic and their impact on clinical practice.

The COVID-19 pandemic has modified the management of urothelial carcinoma (UC). Eighteen months after the onset of the pandemic, a scoping narrative review was able to state that radical cystectomy for UC should not be delayed beyond 10 weeks when neoadjuvant chemotherapy (NAC) was administered and 12 weeks when it was not. NAC should be considered when imminent chemotherapy cannot be performed. Early cystectomy should not be delayed when indicated for patients with high-risk non-MIBC. Patients with non-MIBC should still receive their induction doses of intravesical instillations. Diagnostic cystoscopy should not be deferred in symptomatic patients. Surgical management of upper tract urothelial carcinoma (UTUC) allows for a wider deferral interval.

Characteristics and Outcome in Non-Puerperal Uterine Inversion.

Chronic non-puerperal uterine inversion is rare and usually associated with uterine pathology with a diagnosis that is challenging. We present the case of a 47-year-old para 4 Caucasian woman with a history of polyfibromatous uterus who was admitted for severe vaginal bleeding for the past 48 hours associated with hemodynamical instability and was refusing any surgery. Pelvic MRI showed the uterus presenting an unusual appearance with a highly vascularized intracavitary leiomyoma protruding through the cervix. Upon deterioration of her status despite an optimal blood transfusion, resuscitation and anti-fibrinolytic treatment, she accepted total abdominal hysterectomy. The diagnosis of uterine inversion was made intraoperatively and confirmed on histopathologic examination. It revealed two side-by-side benign fundal leiomyomas which had collapsed the fundus and protruded partly from the cervix. Non-puerperal chronic inversion of the uterus is rare, and its diagnosis should be based on ultrasound, pelvic MRI and a high index of suspicion, allowing rapid diagnosis and treatment and thus decreasing patient morbidity and mortality.

Multiparametric MRI with in-bore targeted biopsy in the diagnostic pathway of prostate cancer: Data from a single institution experience.

BACKGROUND: Accuracy of multiparametric MRI (mpMRI) for the detection of significant prostate cancer (CaP) varies in the literature as only few studies use radical prostatectomy specimens as their gold standard. On another hand, MRI-targeted prostate biopsy is emerging as an alternative to the traditional randomized biopsy, with a higher detection rate of high-grade cancers. However, data on MRI guided in bore biopsy is lacking. MATERIAL AND METHODS: We reviewed every patient that had his mpMRI, MRI guided in bore biopsy and radical prostatectomy performed in our hospital between November 2015 and December 2020. The diagnostic performances of both mpMRI and MRI targeted biopsy in sampling PIRADS index lesions were studied, using radical prostatectomy specimens as the gold standard. Sensitivity, specificity, positive predictive value and negative predictive value of mpMRI for detecting T3 stage, extra-capsular extension, seminal vesicles involvement and lymph node disease were also evaluated. RESULTS: Sixty-two met our inclusion criteria. For PIRADS≥3 lesions, sensitivity and positive predictive value for detecting clinically significant CaP were of 83.5% and 94.7%. A total of 32.2% prostate cancers on targeted biopsy were upgraded on final pathology, with an upgrading to ISUP≥2 in 3.2% and to ISUP≥3 in 14.5%. A total of 20.9% of cancers were downgraded but without any downgrading to ISUP 1. When final pathology is taken as a gold standard, sensitivity of mpMRI was 31.8% for T3 staging prediction, 30.0% for extra-capsular extension, 28.7% for seminal vesicles involvement and 66.7% for lymph node disease prediction. Specificity was 89.3%, 93.1%, 95.3%, and 92.7%, respectively. CONCLUSION: mpMRI has an acceptable accuracy for the prediction of significant CaP and index lesion detection but is unreliable for CaP staging. Comparison between pathology and biopsy results revealed that the in-bore biopsy technique has an upgrading and downgrading rate comparable in the literature to fusion biopsy, but higher than the combined biopsy approach.

The place of 5-aminolaevulinic acid-photodynamic therapy in the treatment landscape of urethral warts: A systematic review.

BACKGROUND: Human papilloma virus (HPV) infection is the most common sexually transmitted disease worldwide and the main cause of genital warts. Clear recommendations for the management of urethral warts, which are often hard to detect and difficult to treat, are still lacking. OBJECTIVE: To summarize all available data describing treatment modalities of urethral warts, compare their efficacy and side effects, and provide physicians a treatment strategy outline. MATERIAL AND METHODS: Till June 2020, we conducted a systematic review of articles studying the different treatment modalities of urethral condylomas. A chi-square test was used to compare the recurrence rates between treatment modalities, the complete clearance rates at first follow-up and the rates of adverse events. RESULTS: A total of 26 articles with 1730 patients were included in our review. 61 % of patients were deemed completely cured on the first follow-up while 21 % recurred. 5-aminolevulinic acid (ALA) mediated photodynamic therapy (PDT) was the most common treatment and yielded the lowest recurrence rate (7.5 %) followed by laser therapy (24 %) and topical therapy (31 %) (p < 0.01). ALA-PDT resulted in a higher rate of clearance on follow up (96 %) compared to laser therapy (69 %) and topical therapy (14 %) (p < 0.01). Adverse events were more frequent in the ALA-PDT group (69 %) compared to laser therapy (28 %) and topical treatment (30 %) (p < 0.01). CONCLUSION: ALA-PDT appears to be the most effective treatment of urethral condylomas in term of clearance and recurrence rate, but with a higher risk of adverse events. Management should be tailored to the type of lesion found at presentation.

Urodynamics in patients with multiple sclerosis: is it necessary? A randomized-controlled trial.

BACKGROUND: The need for complete urodynamic evaluation in Multiple Sclerosis (MS) patients with Lower Urinary Tract Symptoms (LUTS) is not fully established in the literature. The objective was to evaluate the effect of urodynamics in MS patients with LUTS on treatment outcomes. METHODS: MS patients with LUTS were recruited. On their first visit, urinary symptoms, symptom bother and urologic quality-of-life were evaluated using standardized questionnaires. On their second visit, patients were randomized into two groups: Group A underwent uroflowmetry, and Group B underwent a urodynamic study. Patients received treatment based on the whole evaluation and then were evaluated at 1, 3 and 6 months. RESULTS: Fifty MS patients with LUTS were randomized to 25 patients in each group. All scores decreased significantly after 6 months of treatment in both groups (p < 0.05). However, no differences were found between the two groups at baseline and at 1, 3 and 6 months of treatment (p > 0.05) concerning treatment outcomes. CONCLUSION: A detailed clinical and non-invasive evaluation of MS patients with LUTS seems to be sufficient for prescribing an effective treatment. A urodynamic study does not influence the response to the prescribed treatment in terms of LUTS severity, bother or urologic quality-of-life.

Laparoscopic transperitoneal pudendal nerve and artery release for pudendal entrapment syndrome.

INTRODUCTION: Pudendal nerve and artery entrapment is an underdiagnosed pathology responsible of several urinary, sexual and anorectal complaints. The aim of our study was to evaluate safety and feasibility of laparoscopic transperitoneal pudendal nerve and artery release in a large retrospective cohort of patients with pudendal nerve entrapment syndrome with both a short and long-term follow-up. Technical details and outcomes are also reported. METHODS: A series of 235 patients with pudendal syndrome underwent laparoscopic transperitoneal pudendal canal release between June 2015 and February 2020. Operative data were recorded prospectively for all patients. A complete history, pain visual analog scale (VAS) for perineodynia, and three scores evaluating the main symptoms (USP, IIEF-5, PAC-SYM) were obtained before and at least 24 months after surgery for 32 patients only. Post-operative complications were also evaluated using Clavien-Dindo classification at regular interval. RESULTS: The mean operating time per side was 33.9 ± 6.8 min and the average hospital stay was 1.9 ± 0.3 days. Blood loss was 20 cc ± 10 cc with no patients needing transfusion. The only significant per-operative complication was hemorrhage (600 ml) in one patient induced by a pudendal artery laceration, successfully treated by laparoscopic suturing. Post-operative complications were noted in 18.7% of patients with no serious Clavien-Dindo complications. Perineodynia VAS dropped from 6.8 ± 0.9 to 2.2 ± 1.8 after surgery (p < 0.001). Mean IIEF-5 scores significantly improved one month after the surgery (15.2 vs 19.3, p = 0.036). Mean USP scores significantly improved for the dysuria domain (4.2 vs 1.6, p = 0.021) but not for stress urinary incontinence (3.9 vs 4.1, p = 0.082) or overactive bladder symptoms (14.1 vs 13.8, p = 0.079). Mean PAC-SYM scores significantly improved after the procedure (1.8 vs 1.1, p < 0.001). CONCLUSION: A complete laparoscopic pudendal nerve and artery release, from the sciatic spine through the Alcock's canal, is a fast and safe surgery with promising functional results. A large prospective trial is needed to validate such an approach.

Pudendal nerve release for lower urinary tract symptoms in young males.

OBJECTIVES: The aim of this study was to assess the efficacy of laparoscopic transperitoneal pudendal decompression in the improvement of refractory lower urinary tract symptoms (LUTS) in young males presenting with clinical features of pudendal nerve entrapment with no known comorbidities that could explain their LUTS. METHODS: This is a prospective pilot study involving patients suffering from LUTS refractory to standard treatment and clinical features of pudendal nerve entrapment on physical examination. They underwent laparoscopic transperitoneal pudendal decompression. International Prostate Symptom Score (IPSS) and maximal flow (Qmax) on uroflowmetry were evaluated before and 3 months after the procedure. RESULTS: Five male patients aged 34 ± 4 years were recruited. The median IPSS differed significantly before and 3 months after the procedure (18 vs 8, P = .042); likewise, median Qmax differed significantly before and 3 months after the procedure (12 vs 18 mL/s, P = .042). CONCLUSION: Pudendal nerve entrapment syndrome should be considered as a main differential diagnosis for refractory LUTS in young males with no other comorbidities. When clinical features of pudendal nerve entrapment are present, laparoscopic transperitoneal pudendal decompression relieves LUTS in these young males.

Engagement of medical specialty trainees in research: experience at a Lebanese medical school.

BACKGROUND: Many challenges exist to engaging medical students and postgraduate trainees in research in low and middle-income countries. AIMS: This study aimed to assess the motivation of and opportunities for postgraduate medical specialty trainees to engage in medical research, and the perceived obstacles to undertaking research in Lebanon. METHODS: A questionnaire-based survey of all postgraduate clinical trainees was conducted at Saint Joseph University of Beirut medical school, Lebanon. Logistic regression analysis was used to determine factors associated with engaging in research. Odds ratios (OR) and 95% confidence intervals (CI) are presented. RESULTS: Of 290 trainees, 252 (87%) completed the questionnaire; 40.1% were specializing in medicine, 25.8% in surgery and 34.1% in other fields. A total of 122 trainees had participated in research projects: 85.2% in data collection, 83.6% in writing of abstracts, 69.7% in writing papers for publication, 58.2% in project design and 57.4% in data analysis. Most trainees had produced considerable research output (82.0%), with an average of 2.5 publications. Enhancing their curriculum vitae (OR = 1.90, 95% CI 0.84-4.30) and enjoying research (OR = 2.05, 95% CI 0.94-4.44) were not motivational factors for engaging in research. Trainees were frustrated by the limited research opportunities, citing lack of time as a main factor. CONCLUSION: There is a need for additional formal and informal support programmes to encourage postgraduate trainees to engage more in research.