Physical injuries and burns among refugees in Lebanon: implications for programs and policies.

BACKGROUND: Refugees are prone to higher risks of injury due to often austere living conditions, social and economic disadvantages, and limited access to health care services in host countries. This study aims to systematically quantify the prevalence of physical injuries and burns among the refugee community in Western Lebanon and to examine injury characteristics, risk factors, and outcomes. METHODS: We conducted a cluster-based population survey across 21 camps in the Beqaa region of Lebanon from February to April 2019. A modified version of the 'Surgeons Overseas Assessment of Surgical Need (SOSAS)' tool (Version 3.0) was administered to the head of the refugee households and documented all injuries sustained by family members over the last 12 months. Descriptive and univariate regression analyses were performed to understand the association between variables. RESULTS: 750 heads of households were surveyed. 112 (14.9%) households sustained injuries in the past 12 months, 39 of which (34.9%) reported disabling injuries that affected their work and daily living. Injuries primarily occurred inside the tent (29.9%). Burns were sustained by at least one household member in 136 (18.1%) households in total. The majority (63.7%) of burns affected children under 5 years and were mainly due to boiling liquid (50%). Significantly more burns were reported in households where caregivers cannot lock children outside the kitchen while cooking (25.6% vs 14.9%, p-value = 0.001). Similarly, households with unemployed heads had significantly more reported burns (19.7% vs. 13.3%, p value = 0.05). Nearly 16.1% of the injured refugees were unable to seek health care due to the lack of health insurance coverage and financial liability. CONCLUSIONS: Refugees severely suffer from injuries and burns, causing substantial human and economic repercussions on the affected individuals, their families, and the host healthcare system. Resources should be allocated toward designing safe camps as well as implementing educational awareness campaigns specifically focusing on teaching about heating and cooking safety practices.

Concurrent radical cystectomy and nephroureterectomy indications and outcomes: a systematic review and comparative analysis.

Introduction: Urothelial carcinoma can arise from the urinary bladder or from the upper urinary tract. In some instances, urinary bladder cancer (UBC) and upper tract urothelial carcinoma (UTUC) can be concurrently diagnosed, necessitating a combined radical cystectomy (RC) with radical nephroureterectomy (RNU). A systematic review was done on the combined procedure exploring outcomes and indications, in addition to a comparative analysis between the combined procedure and cystectomy alone. Methods: For the systematic review, three databases (Embase, PubMed, and Cochrane) were queried, selecting only studies that included intraoperative and perioperative data. For the comparative analysis, using the NSQIP database, CPT codes for RC and RNU were used to identify two cohorts, one with RC and RNU and one with RC alone. A descriptive analysis was performed on all preoperative variables, and propensity score matching (PSM) was performed. Postoperative events were then compared between the two matched cohorts. Results: For the systematic review, 28 relevant articles were included amounting to 947 patients who underwent the combined procedure. The most common indication was synchronous multifocal disease, the most common approach was open surgery, and the most common diversion technique was using an ileal conduit. Almost 28% of patients required blood transfusion and remained in the hospital for an average of 13 days. The most common postoperative complication was prolonged paralytic ileus. For the comparative analysis, 11,759 patients were included of which 97.5% underwent RC only and 2.5% underwent the combined procedure. After PSM, the cohort that had undergone the combined procedure showed an increased risk of renal injury, increased readmission rates, and increased reoperation rates. Whereas the cohort that had undergone RC only showed an increased risk of deep venous thrombosis (DVT), sepsis, or septic shock. Conclusion: A combined RC and RNU is a treatment option for concurrent UCB and UTUC that should be cautiously utilized as it is associated with high morbidity and mortality. Patient selection, discussion of the risks and benefits of the procedure, and explanation of the available treatment options remain the most important pillars in managing patients with this complex disease.

A novel radical prostatectomy specific index (PSI) for the prediction of major cardiovascular events following surgery.

PURPOSE: Prostate cancer patients tend to be older with multiple comorbidities and are thus at increased risk for postoperative cardiovascular events after radical prostatectomy (RP). Thus, proper patient selection strategies are essential to decide for or against a surgical approach. We aimed to derive a prostatectomy specific index (PSI) for patients undergoing RP and compare its performance to universally used indices. METHODS: The cohort was derived from National Surgical Quality Improvement Program database between 2005 and 2012. The primary outcome was incidence of major adverse cardiovascular events at 30 days post-surgery including: death, myocardial infarction, or stroke. A multivariable logistic regression model was constructed, performance and calibration were evaluated using a ROC analysis and the Hosmer-Lemeshow test, the PSI index was derived and compared to the RCRI and AUB-HAS2 indices. RESULTS: A total of 17,299 patients were included in our cohort, with a mean age of 62 ± 7.4 years. Seventy three patients had a cardiac event post RP. The final PSI index encompassed six variables: history of heart disease, age, anemia, American society of anesthesiology class, surgical approach, and hypertension. The PSI ROC analysis provided C-statistic = 0.72, calibration R2 = 0.99 and proper goodness of fit. In comparison, the C-statistics of RCRI and AUB-HAS2 were found to be 0.57 and 0.65, respectively (p value < 0.001). CONCLUSION: The PSI model is a procedure tailored index for prediction of major cardiovascular events post RP. It was calibrated using a large national database aiming to optimize treatment selection strategies for prostate cancer patients.

Probiotics Properties: A Focus on Pregnancy Outcomes.

A healthy microbiome plays an important role in the prevention of illness and maintenance of overall health, including reproductive health. Although the therapeutic advantages of probiotics have been shown to run across multiple organ systems, their role in pregnancy is not well explored. The aim of this review is to highlight the potential advantages and adverse effects of probiotics in pregnancy. Data were collected from the literature over the past decade using PubMed, Medline, Google Scholar, Ovid, Scopus, and Science Direct. A total of 40 articles were utilized in this review. Collected data indicated that prenatal and post-natal supplementation with lactobacilli alone or lactobacilli with Bifidobacterium spp. seems to be protective. Probiotics may improve insulin resistance and consequently reduce the risk of gestational diabetes. Probiotics may also reduce anxiety and depression by influencing brain activity. Additionally, they interfere with vaginal flora to make it friendlier to beneficial bacteria, and enhance anti-inflammatory or reduce pro-inflammatory cytokines. They may also decrease eczema in breastfed infants and prevent allergic reactions by downregulating Th2 responses to specific allergens from mid to late gestation. Leveraging the cervicovaginal microbiota could promote a number of positive pregnancy-related health outcomes. Caution should be exercised in the selection, dosing, and monitoring of probiotics administration. More comprehensive randomized clinical trials are needed to reach a more meaningful evidence-based clinical knowledge.

Major adverse cardiovascular events following partial nephrectomy: a procedure-specific risk index.

Introduction: Partial nephrectomy (PN) is associated with a non-negligible risk of postoperative cardiovascular morbidity and mortality. Identification of high-risk patients may enable optimization of perioperative management and consideration of alternative approaches. The authors aim to develop a procedure-specific cardiovascular risk index for PN patients and compare its performance to the widely used revised cardiac risk index (RCRI) and AUB-HAS2 cardiovascular risk index. Methods: The cohort was derived from the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) database. The primary outcome was the incidence of major adverse cardiovascular events (MACE), defined as 30-day postoperative incidence of myocardial infarction, stroke, or mortality. A multivariate logistic regression model was constructed; performance and calibration were evaluated using an ROC analysis and the Hosmer-Lemeshow test and compared to the RCRI and the AUB-HAS2 index. Results: In a cohort of 4795 patients, MACE occurred in 52 (1.1%) patients. A univariate analysis yielded 13 eligible variables for entry into the multivariate model. The final PN-A4CH model utilized six variables: Age ⩾75 years, ASA class >2, Anemia, surgical Approach, Creatinine >1.5, and history of Heart disease. Index ROC analysis provided a C-statistic of 0.81, calibration R 2 was 0.99, and sensitivity was 85%. In comparison, the RCRI and AUB-HAS2 C-statistics were 0.59 and 0.68, respectively. Conclusion: This study proposes a novel procedure-specific cardiovascular risk index. The PN-A4CH index demonstrated good predictive ability and excellent calibration using a large national database and may enable further individualization of patient care and optimization of patient selection.

Learning curve in aquablation: an international multicenter study.

OBJECTIVES: To describe and analyze the learning curve (LC) of aquablation for the treatment of benign prostatic obstruction and determine the number of cases needed to achieve acceptable surgical safety, efficiency, and efficacy. METHODS: A retrospective analysis of prospectively maintained aquablation databases from France, Lebanon, and Spain was conducted. The combined LC of three surgeons was defined by trifecta and pentafecta outcomes. Trifecta reflected efficiency and safety: operative time < 60 min, hemoglobin reduction ≤ 2 mg/dL, and no 90 day Clavien-Dindo grade ≥ 2 complications. Pentafecta reflected effectiveness: percent reduction in International Prostate Symptom Score (IPSS) and ejaculation preservation. The combined LC was plotted using a moving average with polynomial fitting. RESULTS: The cohort included 175 consecutive patients. Median (IQR) prostate volume was 70 (50-91) cc, and baseline IPSS was 23 (18-27). The achievement of trifecta exceeded 50% after 4 cases, and 70% after 50 cases. Pentafecta achievement exceeded 50% after 38 cases. Logistic regression showed significant improvement in hemoglobin reduction and ejaculation preservation. Grade ≥ 2 complication was not affected by experience, and neither was 3 month %IPSS reduction as 94% of patients showed ≥ 50% symptoms' improvement. CONCLUSION: Aquablation is associated with a quick learning curve for the defined trifecta and pentafecta outcomes. It provided effective LUTS relief and low complication rates independent of surgeon experience. Hemoglobin drop and ejaculatory function preservation were the two factors influenced by the surgeons' LC. Training to reduce operative time, standardization of hemostasis techniques, and early assistance to improve veru-protection zone planning are keys to quicker learning.

Risk of Postoperative Renal Failure in Radical Nephrectomy and Nephroureterectomy: A Validated Risk Prediction Model.

INTRODUCTION: The study aimed to construct and validate a risk prediction model for incidence of postoperative renal failure (PORF) following radical nephrectomy and nephroureterectomy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2005-2014 were used for the derivation cohort. A stepwise multivariate logistic regression analysis was conducted, and the final model was validated with an independent cohort from the ACS-NSQIP database years 2015-2017. RESULTS: In cohort of 14,519 patients, 296 (2.0%) developed PORF. The final 9-factor model included age, gender, diabetes, hypertension, BMI, preoperative creatinine, hematocrit, platelet count, and surgical approach. Model receiver-operator curve analysis provided a C-statistic of 0.79 (0.77, 0.82; p < 0.001), and overall calibration testing R2 was 0.99. Model performance in the validation cohort provided a C-statistic of 0.79 (0.76, 0.81; p < 0.001). CONCLUSION: PORF is a known risk factor for chronic kidney disease and cardiovascular morbidity, and is a common occurrence after unilateral kidney removal. The authors propose a robust and validated risk prediction model to aid in identification of high-risk patients and optimization of perioperative care.

Physical trauma and injury: A multi-center study comparing local residents and refugees in Lebanon.

BACKGROUND: Refugees are susceptible to various types of injury mechanisms associated with their dire living conditions and settlements. This study aims to compare and characterize the emergency department admissions due to physical trauma and injuries among local residents and refugees in greater Beirut. METHODS: This epidemiological study analyzes injury incidence and characteristics of patients presenting to Emergency Departments of 5 sentinel hospitals between 2017 and 2019. Using the WHO Injury Surveillance Guidelines and Pan-Asia Trauma Outcomes Study form, an injury data surveillance form was designed and used in hospital settings to collect data on injuries. Chi-square test analysis was performed to compare differences in injury characteristics between local residents and refugees. Regression models were constructed to assess the effect of being a refugee on the characteristics of injuries and outcomes of interest. RESULTS: A total of 4847 injuries (3933 local residents and 914 refugees) were reported. 87.4% of the total injuries among refugees were sustained by the younger age groups 0-45 years compared to 68.8% among local residents. The most prevalent injury mechanism was fall (39.4%) for locals and road traffic injury (31.5%) for refugees. The most injured body part was extremities for both populations (78.2% and 80.1%). Injuries mostly occurred at home or its vicinity (garden or inside the camp) for both populations (29.3% and 23.1%). Refugees sustained a higher proportion of injuries at work (6%) compared to locals (1.3%). On multivariate analysis, refugee status was associated with higher odds of having an injury due to a stab/gunshot (odds ratio (OR) = 3.392, 95% confidence interval (CI) = 2.605-4.416), having a concussion injury (OR = 1.718, 95% CI = 1.151-2.565), and being injured at work (OR = 4.147, 95% CI = 2.74-6.278). Refugee status was associated with increased odds of leaving the hospital with injury-related disability (OR = 2.271, 95% CI = 1.891-2.728)]. CONCLUSIONS: Injury remains a major public health problem among resident and refugee communities in Beirut, Lebanon. Refugees face several injury-related vulnerabilities, which adversely affect their treatment outcomes and long-term disabilities. The high prevalence of occupational and violence-related injuries among refugees necessitates the introduction of targeted occupational safety and financial security interventions, aiming at reducing injuries while enhancing social justice among residents.

Do Medical Students' Learning Styles and Approaches Explain Their Views and Behavior Regarding Lecture Attendance?

INTRODUCTION: Medical students' attendance at lectures, particularly in the preclinical years, has been steadily declining over the years. One of the many explanations offered for this observation is that students have different learning styles and approaches, such that not all of them benefit from attending lectures; however, no studies have specifically examined this possibility. While there is evidence against learning styles as affecting objective measures of learning, they are associated with subjective measures of learning and may therefore influence student behavior. We hypothesized that students' learning styles and/or approaches influence their views about the value and purpose of lectures and their motivation to attend them, which, in turn will affect their behavior. MATERIALS AND METHODS: A LimeSurvey was distributed to all preclinical students at the American University of Beirut. The survey included questions about demographic data, self-reported attendance rates in Year 1 of medical school, two validated and standardized questionnaires assessing the students' learning styles (visual, auditory, kinesthetic, tactile, group, individual) and learning approaches (superficial, deep, strategic), and a series of questions exploring the students' views about the purpose and value of lectures and their motivation to attend lectures. RESULTS: No associations were found between learning styles or approaches and attendance rates, but this may have been confounded by the mandatory attendance policy at the time. There were, however, a few positive associations between some learning styles or approaches and the students' views about the value of attending lectures. In particular, students with high scores as auditory learners tended to see absolutely no value in attending lectures, and those with high scores as group, auditory or visual learners, tended to see less value in taking their own notes in lectures. Students with superficial approaches to learning felt that watching videos of a lecture provides equivalent education to attending a lecture. There were no statistically significant associations with either the perceived purpose of lectures or the motivation to attend lectures after correction for multiple testing. CONCLUSIONS: This study reveals that except for some interesting findings related to auditory learners, differences in learning styles or approaches among students cannot adequately explain differences in their attitudes, and likely, behavior, regarding lecture attendance. The idea that learning styles and approaches can influence educational preferences and outcomes, while attractive and intuitive, continues to require supporting evidence. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-021-01362-3.

Risk factors for wound dehiscence following radical cystectomy: a prediction model.

OBJECTIVES: Radical cystectomy (RC) is a complex urologic procedure performed for the treatment of bladder cancer and causes significant morbidity. Wound dehiscence (WD) is a major complication associated with RC and is associated with multiple risk factors. The objectives of this study are to identify clinical risk factors for incidence of WD and develop a risk-prediction model to aid in patient risk-stratification and improvement of perioperative care. MATERIALS AND METHODS: The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) database was used to derive the study cohort. A univariate analysis provided nine variables eligible for multivariate model entry. A stepwise logistic regression analysis was conducted and refined considering clinical relevance of the variables, and then bootstrapped with 1000 samples, resulting in a five-factor model. Model performance and calibration were assessed by a receiver operated curve (ROC) analysis and the Hosmer-Lemeshow test for goodness of fit, respectively. RESULTS: A cohort of 11,703 patients was identified from years 2005 to 2017, with 342 (2.8%) incidences of WD within 30 days of operation. The final five-factor model included male gender [odds ratio (OR) = 2.5, p < 0.001], surgical site infection (OR = 6.3, p < 0.001), smoking (OR = 1.8, p < 0.001), chronic obstructive pulmonary disease (COPD) (OR = 1.9, p < 0.001), and weight class; morbidly obese patients had triple the odds of WD (OR = 2.9, p < 0.001). The ROC analysis provided a C-statistic of 0.76 and calibration R 2 was 0.99. CONCLUSION: The study yields a statistically robust and clinically beneficial five-factor model for estimation of WD incidence risk following RC, with good performance and excellent calibration. These factors may assist in identifying high-risk patients, providing preoperative counseling and thus leading to improvement in perioperative care.

Targeted Therapies in Trial for Non-Resectable Gallbladder Cancer.

PURPOSE: Gallbladder cancer (GBC) is the most common malignancy of the biliary tract. The median survival of the disease is around 6 months. In this study, we explore clinical trials related to non-resectable GBC, determine the shortcomings leading to the lack of development of new treatment, and shed light on possible areas of improvement. METHODS: On April 20, 2019 the authors completed a search on ClinicalTrials.gov for all therapeutic and interventional clinical trials involving non-resectable GBC, without any limits on date or location. Trial characteristics such as duration, phase, sample size, and whether a publication was produced were collected and analyzed. RESULTS: Sixty-two trials met our selection criteria. The average duration of trials was 5 years. Trials were conducted in 8 different countries: most of them in North America (USA and Canada). About 88% of trials were in early phases (I, I/II, and II) and 85% of trials were completed. Only 4 relevant publications were produced from all the trials in our study. Gemcitabine was the most common drug used. Use of gemcitabine alone or in combination with either capecitabine or cisplatin showed significant increase mean progression-free survival. CONCLUSION: This study revealed a low number of trials, lack of geographic diversity, and scarcity of publications concerning non-resectable GBC. Adequate management of is of great importance to reach effective therapies for this disease.

A large number of COVID-19 interventional clinical trials were registered soon after the pandemic onset: a descriptive analysis.

BACKGROUND AND OBJECTIVE: There is a pressing need for evidence-based interventions to address the devastating clinical and public health effects of the coronavirus disease 2019 (COVID-19) pandemic. The number of registered trials related to COVID-19 is increasing by the day. The objective of this study was to describe the characteristics of the currently registered interventional clinical trials related to COVID-19. METHODS: We searched the World Health Organization's International Clinical Trials Registry Platform on May 15th, 2020. We included any entry that is related to COVID-19. We abstracted and then descriptively analyzed the following characteristics of the registered trials: study design, status, phase, primary endpoints, experimental interventions, and geographic location among other qualifiers. RESULTS: We identified 1,308 eligible registered trials. Most trials were registered with ClinicalTrials.gov (n = 703; 53.7%) and the Chinese Clinical Trial Registry (n = 291; 22.2%). The number of participants to be enrolled across these trials was 734,657, with a median of 110 participants per trial. The most commonly studied intervention category was pharmacologic (n = 763; 58.3%), with antiparasitic medications being the most common subcategory. Although over half of the trials were already recruiting, we identified published peer-reviewed results for only 8 of those trials. CONCLUSION: There is a relatively large number of registered trials but with very few results published so far. Although our findings suggest an appropriate initial response by the research community, the real challenge will be to get these trials completed, published, and translated into practice and policy.

A Bibliometric Analysis of COVID-19 Research Activity: A Call for Increased Output.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) has impacted many countries across all inhabited continents, and is now considered a global pandemic, due to its high rate of infectivity. Research related to this disease is pivotal for assessing pathogenic characteristics and formulating therapeutic strategies. The aim of this paper is to explore the activity and trends of COVID-19 research since its outbreak in December 2019. METHODS: We explored the PubMed database and the World Health Organization (WHO) database for publications pertaining to COVID-19 since December 2019 up until March 18, 2020. Only relevant observational and interventional studies were included in our study. Data on COVID-19 incidence were extracted from the WHO situation reports. Research output was assessed with respect to gross domestic product (GDP) and population of each country. RESULTS: Only 564 publications met our inclusion criteria. These articles came from 39 different countries, constituting 24% of all affected countries. China produced the greatest number of publications with 377 publications (67%). With respect to continental research activity, Asian countries had the highest research activity with 434 original publications (77%). In terms of publications per million persons (PPMPs), Singapore had the highest number of publications with 1.069 PPMPs. In terms of publications per billion-dollar GDP, Mauritius ranked first with 0.075. CONCLUSION: COVID-19 is a major disease that has impacted international public health on a global level. Observational studies and therapeutic trials pertaining to COVID-19 are essential for assessing pathogenic characteristics and developing novel treatment options.