Low rate of human papillomavirus vaccination among schoolgirls in Lebanon: barriers to vaccination with a focus on mothers' knowledge about available vaccines.

BACKGROUND: Human papillomavirus (HPV) infection is an established predisposing factor of cervical cancer. In this study, we assessed the awareness about genital warts, cervical cancer, and HPV vaccine among mothers having girls who are at the age of primary HPV vaccination attending a group of schools in Lebanon. We also assessed the rate of HPV vaccination among these girls and the barriers to vaccination in this community. SUBJECTS AND METHODS: This is a cross-sectional, school-based survey. A 23-item, self-administered, anonymous, pretested, structured questionnaire with closed-ended questions was used to obtain data. The questionnaire was sent to the mothers through their student girls, and they were asked to return it within a week. Data were analyzed using the Statistical Package for Social Sciences version 21.0. Bivariate analysis was performed using the chi-square test to compare categorical variables, whereas continuous variables were compared using the Student's t-test. Fisher's exact test was used when chi-square test could not be employed. RESULTS: The response rate in our survey was 39.4%. Among the responders, the rate of awareness about HPV infection was 34%, where 72% of the mothers had heard about cervical cancer, and 34% knew that a vaccine is available to prevent cervical cancer. HPV vaccination uptake rate was 2.5%. This lack of vaccination was primarily attributed to the low rate of mothers' awareness about the vaccine (34%). Factors significantly affecting awareness about the vaccine were the mothers' marital age, nationality, level of education, employment, and family income. Barriers to HPV vaccination, other than awareness, were uncertainty about safety or efficacy of the vaccine, conservative ideas of mothers regarding their girls' future sexual life, and relatively high price of the vaccine. CONCLUSION: Vaccine uptake is low among eligible girls attending this group of schools. The barriers to vaccination are multiple; the most important one is the mothers' lack of knowledge about HPV, cervical cancer, and the modes of prevention. Awareness campaigns along with a multimodal strategy that targets the identified barriers would be recommended to achieve higher rates of HPV vaccination.

Nerve stimulator-guided pudendal nerve block vs general anesthesia for postoperative pain management after anterior and posterior vaginal wall repair: a prospective randomized trial.

STUDY OBJECTIVE: Compare the effectiveness of nerve stimulator-guided pudendal nerve block (PNB) vs general anesthesia (GA) for anterior and posterior (AP) colporrhaphy in terms of pain relief and analgesic consumption within 24 and 48 hours postoperatively. DESIGN: Prospective randomized trial. PATIENTS: Fifty-seven patients whose ages ranged between 20 and 53 years scheduled to undergo AP colporrhaphy due to the presence of cystorectocele. INTERVENTIONS: Patients were randomly assigned into 2 groups receiving either nerve stimulator-guided PNB (n = 28) or GA (n = 29). A total volume of 0.7 mL/kg of the local anesthetic mixture was injected at 4 sites. MAIN RESULTS: Both groups were similar with respect to age, weight, height, and surgery duration. There was a significant difference in average pain scores within the first and second postoperative days (P values = .005 and .004, respectively). Total analgesic consumption (ketoprofen and tramadol) was significantly lower in the PNB within the first (P values = .018 and .010) and second postoperative days (P values = .041 and .011), respectively. Return to normal daily activity was significantly (P< .0001) shorter in the PNB group compared with the GA group (3.6 days vs 12.2 days). A total of 71.4% of the patients in the PNB group were satisfied compared with 27.8% in the GA group (P< .0001). Surgeon satisfaction was significantly higher in the PNB group (82.1% vs 34.5%, P< .0001). CONCLUSION: This randomized controlled trial demonstrated that nerve stimulator-guided PNB could be used as an alternative to GA for AP repair of stages I and II prolapse because it is associated with less postoperative pain and analgesic consumption, in addition to shorter duration of recovery.

Spectrum of Phenotypes Associated with Mutations in LRBA.

To date, several germline mutations have been identified in the LRBA gene in patients suffering from a variety of clinical symptoms. These mutations abolish the expression of the LRBA protein, leading to autoimmunity, chronic diarrhea, B-cell deficiency, hypogammaglobulinemia, functional T-cell defects and aberrant autophagy. We review the clinical and laboratory features of patients with LRBA mutations and present five novel mutations in eight patients suffering from a multitude of clinical features.

Epidemiology and characteristics of urinary tract infections in children and adolescents.

BACKGROUND: Urinary tract infections (UTIs) are among the most common infections in the pediatric population. Over the last two decades, antibiotic resistance is increasing significantly as extended spectrum beta lactamase (ESBL) producing organisms are emerging. The aim of this study is to provide a comprehensive view of the epidemiologic characteristics of UTIs in hospitalized children, examine the risk factors of UTIs caused by ESBL-producing organisms, and determine the resistance patterns in the isolated organisms over the last 10 years. METHODS: Retrospective chart review was conducted at two Lebanese medical centers. Subjects were identified by looking at the following ICD-9 discharge codes: "Urinary tract infection," "UTI," "Cystitis," and/or "Pyelonephritis." Children less than 18 years of age admitted for UTI between January 1st, 2001 and December 31st, 2011 were included. Cases whose urine culture result did not meet our definition for UTI were excluded. Chi-square, Fisher's exact test, and multivariate logistic regression were used to determine risk factors for ESBL. Linear regression analysis was used to determine resistance patterns. RESULTS: The study included 675 cases with a median age of 16 months and female predominance of 77.7% (525 cases). Of the 584 cases caused by Escherichia coli or Klebsiella spp, 91 cases (15.5%) were found to be ESBL-producing organisms. Vesico-ureteral reflux and previous antibiotics use were found to be independent risk factors for ESBL-producing E. coli and Klebsiella spp. (p < 0.05). A significant linear increase in resistance to all generations of Cephalosporins (r (2) = 0.442) and Fluoroquinolones (r (2) = 0.698) was found. CONCLUSION: The recognition of risk factors for infection with ESBL-producing organisms and the observation of increasing overall resistance to antibiotics warrant further studies that might probably lead to new recommendations to guide management of UTIs and antibiotic use in children and adolescents.

Effect of one anesthetic exposure on long-term behavioral changes in children.

STUDY OBJECTIVE: To determine the association between one anesthetic exposure and behavioral outcome at age 10 to 12 years. DESIGN: Retrospective comparative study. SETTING: University-affiliated pediatrics department. MEASUREMENTS: The medical records of children who underwent anesthesia between January 2004 and December 2005 at our institution were reviewed. The records of 292 children were included in the study group and 300 children in the control group. The study group involved children who had one anesthetic exposure before age of 4 years and the control group had children who were not exposed to anesthesia. The primary outcome was behavioral change as assessed by the Eyberg Child Behavior Inventory (ECBI) questionnaire. MAIN RESULTS: The rate of behavioral abnormalities before the age of 11 years was 28.4% in the study group (P<0.001) and 5.7% in the control group. The risk of developing behavioral abnormalities was prominent in children being exposed to surgery versus those exposed during a diagnostic procedure (32.4% vs 4.8%; P<0.0001). Eighty-three point nine percent of the children who were exposed to longer duration anesthesia (more than 3 hrs) had behavioral abnormalities (P<0.0001), while 48.8% of children who received anesthesia at younger ages (0 - 6 mos) had behavioral abnormalities (P<0.0001). Exposure to multiple anesthetic agents versus one anesthetic agent was a significant risk factor for development of behavioral abnormalities (P<0.0001). CONCLUSION: The incidence of behavioral abnormalities increased when anesthesia and surgery were accompanied by younger age, longer duration of surgery, and use of multiple anesthetic agents.

Short-term neonatal outcome in singleton, late preterm deliveries: a three-year experience at a single Lebanese center.

BACKGROUND: There has been a decrease in the mean gestational age at delivery worldwide mostly due to an increase in deliveries occurring at late preterm period (LPP) with a concomitant rise in the rate of morbidities among newborns delivered at this period. OBJECTIVES: To report the frequency of common short-term neonatal morbidities in infants born at LPP (between 34(0/7) and 36(6/7) weeks' gestation) and to compare these frequencies with those of full-term infants born at our institution. MATERIALS & METHODS: A descriptive cohort study (2008-2010) at Makassed General Hospital. All deliveries occurring at LPP constituted the study group (n = 361), while births at or beyond 37 weeks' gestation were considered as controls (n = 2814). RESULTS: The average rate of deliveries in LPP was 11.4% for the entire study period. The rate of Neonatal Intensive Care Unit admissions, respiratory morbidities, sepsis, jaundice, hypothermia, hypoglycemia and overall neonatal morbidity were all significantly higher in LPP infants when compared to those at term (p-value < 0.013). CONCLUSION: In our cohort of Lebanese newborns delivered at LPP, significantly higher morbidities were encountered when compared to full-term newborns. Every possible effort should be exerted to avoid elective deliveries during LPP in order to curb the incidence of neonatal morbidities.

The effectiveness of pudendal nerve block versus caudal block anesthesia for hypospadias in children.

BACKGROUND: Caudal block (CB) has some disadvantages, one of which is its short duration of action after a single injection. For hypospadias repair, pudendal nerve block (PNB) might be a suitable alternative since it has been successfully used for analgesia for circumcision. We evaluated PNB compared with CB as measured by total analgesic consumption 24 hours postoperatively. METHODS: In this prospective, double-blinded study, patients were randomized into 2 groups, either receiving CB or nerve stimulator-guided PNB. In the PNB group, patients were injected with 0.3 mL/kg 0.25% bupivacaine and 1 µg/kg clonidine. In the CB group, patients were injected with 1 mL/kg 0.25% bupivacaine and 1 µg/kg clonidine. Analgesic consumption was assessed during the first 24 hours postoperatively. The "objective pain scale" developed by Hannalah and Broadman was used to assess postoperative pain. RESULTS: Eighty patients participated in the study, 40 in each group. The mean age in the PNB group was 3.1 (1.1) years and in the CB group was 3.2 (1.1) years. The mean weights in the PNB and CB groups were 15.3 (2.8) kg and 15.3 (2.2) kg, respectively. The percentage of patients who received analgesics during the first 24 hours were significantly higher in the CB (70%) compared with the PNB group (20%, P < 0.0001). The average amount of analgesics consumed per patient within 24 hours postoperatively was higher in the CB group (paracetamol P < 0.0001, Tramal P =0.003). CONCLUSION: Patients who received PNB had reduced analgesic consumption and pain within the first 24 hours postoperatively compared with CB.

Guided paravertebral blocks with versus without clonidine for women undergoing breast surgery: a prospective double-blinded randomized study.

BACKGROUND: Paravertebral blocks (PVBs) have been introduced as an alternative to general anesthesia for breast cancer surgeries. The addition of clonidine as an adjuvant in PVBs may enhance quality and duration of analgesia and significantly reduce the consumption of analgesics after breast surgery. In this prospective randomized double-blind study, we assessed the significance of adding clonidine to the anesthetic mixture for women undergoing mastectomy. METHODS: Sixty patients were randomized equally into 2 groups, both of which received PVB block, either with or without clonidine. Analgesic consumption was noted up to 2 weeks after the operation. A visual analog scale was used to assess pain postoperatively during the hospital stay, and a numeric rating scale was used when patients were discharged. RESULTS: Analgesic consumption was significantly lower in the clonidine group 48 hours postoperatively with 95% confidence interval (CI) for the difference (-69.5% to -6.6%). Pain scores at rest showed significant reduction in the clonidine group during the period from 24 to 72 hours postoperatively with 95% CI for the ratios of 2 means (1.09-3.61), (2.04-9.04), and (2.54-16.55), respectively, with shoulder movement at 24, 48, and 72 hours postoperatively 95% CI for the ratio of 2 means (1.10-3.15), (1.32-6.38), and (1.33-8.42), respectively. The time needed to resume daily activity was shorter in the clonidine group compared with the control group with 95% CI for the ratio of 2 means (1.14-1.62). CONCLUSION: The addition of clonidine enhanced the analgesic efficacy of PVB up to 3 days postoperatively for patients undergoing breast surgery.

Addition of clonidine and fentanyl: comparison between three different regional anesthetic techniques in circumcision.

BACKGROUND: Several techniques have been used for alleviating post-circumcision pain with regional anesthetics being more effective than systemic opioids. Our aim was to compare the effectiveness of dorsal penile block, ring block (RB) and dorsal penile block associated with RB in reducing post-circumcision pain in children. METHODS: We conducted a prospective randomized double-blind clinical trial on 100 boys aged between 1 month and 5 years undergoing elective circumcision. Each 20 ml of local anesthetic mixture contained 9 ml lidocaine 1% without epinephrine, 9 ml bupivacaine 0.5%, 1 ml fentanyl (50 microg.ml(-1)) and 1 ml clonidine (75 microg.ml(-1)). They were allocated to one of three groups: 33 boys were given a RB with 1-1.5 ml (group 1), 32 had a dorsal penile block with 1.5-4 ml (group 2) and 35 had a combined ring and dorsal penile block with 2.5-5 ml of anesthetic mixture based on the child's age. RESULTS: Ninety-one children (91%) completed the clinical trial (three failed blocks and six follow-up losses). The groups were similar with regard to age, weight, height, duration of surgery and hemodynamic status. The average pain scores were significantly higher with a RB compared with the other two groups (P < 0.05) for the first postoperative day. RB children and dorsal penile block children consumed significantly more analgesics for the first six postoperative hours (P < 0.05). The surgeon's satisfaction was significantly higher with the ring + dorsal penile block group (100%) compared with the other two groups (P = 0.032). CONCLUSION: Dorsal penile block plus RB technique is superior to dorsal penile block alone and RB alone in reducing postcircumcision pain in children.