PRevalence of the Eosinophilic Phenotype Among SeveRE asthma patients in Lebanon: results of the PREPARE study.

BACKGROUND: The prevalence of eosinophilic asthma in Lebanon, one of the most severe phenotypes among severe asthma, is not known. This study aimed at determining the prevalence of the eosinophilic phenotype defined as an eosinophil count ≥ 300 cells/mm3 among severe asthma patients in Lebanon. METHODS: The Lebanese Chapter of the PREPARE study was a national, multicenter, cross-sectional observational study. Patients aged ≥ 12 years with severe asthma were identified and prospectively enrolled during clinic visits and completed the Global Initiative for Asthma (GINA) assessment of asthma control questionnaire. Patients' health characteristics were collected from medical records and blood samples were obtained for measurement of serum IgE levels and blood eosinophils count. RESULTS: Overall, 101 patients (with mean age of 46.3 ± 17.0 years and 73.27% females) with severe asthma were included and, among them, 37% had eosinophilic phenotype, 67.3% had atopic phenotype with IgE > 100 IU/mL and 25.7% patients had overlapping atopic and eosinophilic phenotypes. Close to 80% had late-onset asthma, beyond 12 years of age, and around 85% had at least one severe exacerbation in the 12 months prior to study enrolment. The majority of participants [64.4%] had uncontrolled asthma, 24.7% had partially controlled symptoms and 10.9% had controlled symptoms. 19.8% of participants were on chronic oral corticosteroids, 78.2% had short course treatment of corticosteroids and all were prescribed a combination of inhaled corticosteroids and long-acting beta-agonist. CONCLUSIONS: The majority of patients with severe asthma were uncontrolled of which 37% present with an eosinophilic phenotype, which should be taken into consideration for better management of these patients in view of the novel phenotype-specific therapeutic options.

Diagnosis and management of patients with stage III non­small cell lung cancer: A joint statement by the Lebanese Society of Medical Oncology and the Lebanese Pulmonary Society (Review).

Proper management of stage III non-small cell lung cancer (NSCLC) might result in a cure or patient long-term survival. Management should therefore be preceded by adequate and accurate diagnosis and staging, which will inform therapeutic decisions. A panel of oncologists, surgeons and pulmonologists in Lebanon convened to establish a set of recommendations to guide and unify clinical practice, in alignment with international standards of care. Whilst chest computerized tomography (CT) scanning remains a cornerstone in the discovery of a lung lesion, a positron-emission tomography (PET)/CT scan and a tumor biopsy allows for staging of the cancer and defining the resectability of the tumor(s). A multidisciplinary discussion meeting is currently widely advised for evaluating patients on a case-by-case basis, and should include at least the treating oncologist, a thoracic surgeon, a radiation oncologist and a pulmonologist, in addition to physicians from other specialties as needed. The standard of care for unresectable stage III NSCLC is concurrent chemotherapy and radiation therapy, followed by consolidation therapy with durvalumab, which should be initiated within 42 days of the last radiation dose; for resectable tumors, neoadjuvant therapy followed by surgical resection is recommended. This joint statement is based on the expertise of the physician panel, available literature and evidence governing the treatment, management and follow-up of patients with stage III NSCLC.

The Preschool Asthma Risk Factors Scale: A predictive tool for asthma and respiratory symptoms among preschool children in Lebanon

Background: The Preschool Asthma Risk Factor Scale (PS-ARFS) is a tool that enables clinicians to assess environmental exposure of preschool children, history of parental asthma, and dietary habits. The objective of this study was to evaluate the PS-ARFS ability to predict asthma diagnosis and respiratory symptoms 1 year after baseline assessment and improve the scale if necessary. Methods: A prospective cohort study conducted between November 2018 and March 2019 in three Lebanese schools (from three different Lebanese Governorates) enrolled 515 preschool children aged 3–5 years. Parents completed a detailed questionnaire sent with their children (Phase 1; T0). All parents who participated in Phase 1 were invited to take the same survey by telephone (Phase 2; T1), 1 year later. The interview was conducted by one study-independent person. Of the total sample, 141 (27.4%) children were lost to follow-up. Results: Higher odds of asthma diagnosis at 1 year were significantly associated with playing outside (adjusted odds ratio [aOR] = 3.958) and having a heating system in the bedroom (aOR = 6.986) at baseline, but inversely associated with the female gender (aOR = 0.365). Based on those results, the improved PS-ARFS-I was generated. A higher PS-ARFS-I at T0 was significantly associated with higher odds of asthma at T1 (aOR = 1.08; p < 0.001; 95% confidence interval [CI] 1.05–1.10); similar results were obtained with the longer PS-ARFS (aOR = 1.079; p < 0.001; 95% CI 1.050–1.109). Moreover, among non-asthmatic children at baseline, the PS-ARFS score predicted wheezing and cough at T1 but not bronchial secretions; the PS-ARFS-I score at baseline did not predict symptoms at T1. Conclusion: This study shows that the PS-ARFS-I and PS-ARFS could predict diagnosed asthma at 1-year follow-up (AU)

rs6837671A>G in FAM13A Is a Trans-Ethnic Genetic Variant Interacting with Vitamin D Levels to Affect Chronic Obstructive Pulmonary Disease.

(1) Background and objectives: Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality throughout the world. In addition to genetics, increasing evidence suggests that Vitamin D (VitD) might be involved in different pathogenic mechanisms in COPD. Furthermore, the prevalence of VitD insufficiency is exceptionally high in COPD patients and increases with the severity. Based on the above, we first tested the relation between the top 10 single nucleotide polymorphisms from genome-wide association studies and the risk of COPD. Then, we investigated whether VitD levels might also have a role in COPD. A meta-analysis followed, combining our participants with previously published European and non-European populations (15,716 cases and 48,107 controls). (2) Methods: 631 Lebanese participants were recruited, of which ~28% were affected with COPD. Demographic and clinical data were collected, and DNA was genotyped using Kompetitive allele-specific PCR (KASPTM). Adjusted multiple logistic regression models were used. Bonferroni corrections were also applied. The statistical power was also assessed. (3) Results: Both rs6837671A>G in FAM13A and VitD levels were significantly associated with increased risk of COPD (OR = 1.75, p = 0.01, and OR = 3.10, p < 0.001 respectively). An interaction between rs6837671A>G in FAM13A and VitD levels, which increased COPD risk, was found (OR = 3.35 and p < 0.001). The meta-analysis showed that rs6837671G increases COPD risk in populations from different origins; Europeans, Asians, and now in Middle-Eastern. (4) Conclusions: Our results suggest that rs6837671A>G in FAM13A is a trans-ethnic genetic variant that interact with VitD to affect COPD.

Prevalence of asthma, its correlates, and validation of the Pre-School Asthma Risk Factors Scale (PS-ARFS) among preschool children in Lebanon.

OBJECTIVES: The Asthma Risk Factor Scale (ARFS) is used to screen for asthma in Lebanese preschool children (aged 3-16 years). The study objective was to describe factors associated with asthma, confirm ARFS score validity among Lebanese preschool children, and develop a risk score for asthma diagnosis in this age group (Pre-School Asthma Risk Factor Scale [PS-ARFS]). METHODS: A cross-sectional study enrolled 515 preschool children (November 2018 and March 2019). The ARFS is a 15-item tool that assesses children's environmental exposure, parental history of asthma, and dietary habits. RESULTS: The percentage of asthmatic children was 8.2%. Higher odds of asthma in children were associated with living near a prairie sprayed with pesticides (odds ratio [OR] = 2.33), playing outdoors (OR = 2.89), having a heater in the bedroom (OR = 10.73), attending a nursery (OR = 2.91), having a mother who smokes cigarettes (OR = 3.35) or water pipe (OR = 2.46), a sister with a history of seasonal allergy (OR = 6.81), and a parental history (mother and father) of asthma (OR = 6.15 and OR = 9.83, respectively). Higher ARFS scores (OR = 1.144) were associated with higher odds of asthma. Accordingly, the PS-ARFS was created according to the following formula: ARFS score + (playing outdoor × 2.4) + (heating system in the bedroom × 12.9) + (having attended a nursery × 2.5) (area under the curve = 0.908 [0.860-0.957]; P < 0.001); at value: 14.20, Se = 84.3% and Sp = 90.9%. CONCLUSION: PS-ARFS is suggested for screening of asthma in preschool children in an epidemiological setting and in the absence of spirometry.

Hygiene hypothesis: association between hygiene and asthma among preschool children in Lebanon.

OBJECTIVES: To validate a scale to assess the hygiene hypothesis and the association between hygiene and asthma among Lebanese preschool children aged 3-5 years. METHODS: This cross-sectional study, conducted between November 2018 and March 2019, enrolled 515 preschool children. Asthma and potential risk factors, including hygiene, were assessed using a standardized questionnaire. A specific hygiene hypothesis scale has been generated and validated for this purpose. RESULTS: The hygiene hypothesis scale items converged over a solution of nine factors that had an Eigenvalue over 1, explaining a total of 65.86% of the variance. An acceptable Cronbach's alpha value was recorded for the hygiene hypothesis scale (0.696). Variables correlated with higher odds of asthma were male gender (ORa = 0.41 for females), living near a prairie sprayed with pesticides (ORa = 3.09), having a heating system in the bedroom compared to the sitting room (ORa = 9.97), attending kindergarten (ORa = 2.80), having a mother who smokes waterpipe compared to not smoking (ORa = 3.34), having a mother with a history of asthma (ORa = 5.50), and having respiratory infections (ORa = 14.72). However, the hygiene hypothesis score was not associated with higher odds of asthma (p = 0.881). CONCLUSIONS: The current results suggested that neither home cleaning nor personal cleanliness was correlated with asthma in preschool children. Larger prospective studies that measure the intensity and duration of exposure to each toxicant are suggested to better assess the hygiene hypothesis items and their association with asthma.

Prevalence of asthma, its correlates, and validation of the Pre-School Asthma Risk Factors Scale (PS-ARFS) among preschool children in Lebanon

OBJECTIVES: The Asthma Risk Factor Scale (ARFS) is used to screen for asthma in Lebanese pre-school children (aged 3-16 years). The study objective was to describe factors associated with asthma, confirm ARFS score validity among Lebanese preschool children, and develop a risk score for asthma diagnosis in this age group (Pre-School Asthma Risk Factor Scale [PS-ARFS]).METHODS: A cross-sectional study enrolled 515 preschool children (November 2018 and March 2019). The ARFS is a 15-item tool that assesses children's environmental exposure, parental history of asthma, and dietary habits. RESULTS: The percentage of asthmatic children was 8.2%. Higher odds of asthma in children were associated with living near a prairie sprayed with pesticides (odds ratio [OR] = 2.33), playing out-doors (OR = 2.89), having a heater in the bedroom (OR = 10.73), attending a nursery (OR = 2.91), having a mother who smokes cigarettes (OR = 3.35) or water pipe (OR = 2.46), a sister with a history of seasonal allergy (OR = 6.81), and a parental history (mother and father) of asthma (OR = 6.15 a n d OR = 9.83, respectively). Higher ARFS scores (OR = 1.144) were associated with higher odds of asthma. Accordingly, the PS-ARFS was created according to the following formula: ARFS score + (playing out-door × 2.4) + (heating system in the bedroom × 12.9) + (having attended a nursery × 2.5) (area under the curve = 0.908 [0.860-0.957]; P< 0.001); at value: 14.20, Se = 84.3% and Sp = 90.9%.CONCLUSION: PS-ARFS is suggested for screening of asthma in preschool children in an epidemio-logical setting and in the absence of spirometry

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Hygiene hypothesis: association between hygiene and asthma among preschool children in Lebanon

OBJECTIVES: To validate a scale to assess the hygiene hypothesis and the association between hygiene and asthma among Lebanese preschool children aged 3-5 years. METHODS: This cross-sectional study, conducted between November 2018 and March 2019, enrolled 515 preschool children. Asthma and potential risk factors, including hygiene, were assessed using a standardized questionnaire. A specific hygiene hypothesis scale has been gen­erated and validated for this purpose. RESULTS: The hygiene hypothesis scale items converged over a solution of nine factors that had an Eigenvalue over 1, explaining a total of 65.86% of the variance. An acceptable Cronbach's alpha value was recorded for the hygiene hypothesis scale (0.696). Variables correlated with higher odds of asthma were male gender (ORa = 0.41 for females), living near a prairie sprayed with pesticides (ORa = 3.09), having a heating system in the bedroom compared to the sitting room (ORa = 9.97), attending kindergarten (ORa = 2.80), having a mother who smokes water­pipe compared to not smoking (ORa = 3.34), having a mother with a history of asthma (ORa = 5.50), and having respiratory infections (ORa = 14.72). However, the hygiene hypothesis score was not associated with higher odds of asthma (p = 0.881). CONCLUSIONS: The current results suggested that neither home cleaning nor personal cleanliness was correlated with asthma in preschool children. Larger prospective studies that measure the intensity and duration of exposure to each toxicant are suggested to better assess the hygiene hypothesis items and their association with asthma

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Knowledge, practice pattern and attitude toward asthma management amongst physicians from Nepal, Malaysia, Lebanon, Myanmar and Morocco.

OBJECTIVE: This survey aimed to understand the physicians' practice pattern and challenges faced while treating their patients with asthma in five countries-Malaysia, Nepal, Myanmar, Morocco and Lebanon. METHODS: Questionnaire-based data was gathered from internal medicine doctors (209), general practitioners (206), chest physicians (152) and pediatricians (58) from 232 locations from across the five countries. RESULTS: Of the 816 physicians, 374 physicians encountered at least 5 asthma patients daily. Approximately, 38% physicians always used spirometry for diagnosis and only 12% physicians always recommended Peak flow meter (PFM) for home-monitoring. Salmeterol/fluticasone (71%) followed by formoterol/budesonide (38%) were the most preferred ICS/long-acting beta2-agonists (LABA); Salbutamol (78%) was the most preferred reliever medication. 60% physicians said >40% of their patients were apprehensive to use inhalers. 72% physicians preferred a pressurized metered-dose inhaler (pMDI) to a dry powder inhaler (DPI) with only a third of them using a spacer with the pMDI. 71% physicians believed that using similar device for controller and reliever can be beneficial to patients. Skipping medicines in absence of symptoms (64%), incorrect inhaler technique (48%) and high cost of medication (49%) were considered as major reasons for non-adherence by most physicians. Incorrect inhaler technique (66%) and nonadherence (59%) were considered the most common causes of poor asthma control. CONCLUSIONS: There are opportunities to improve the use of diagnostic and monitoring tools for asthma. Non-adherence, incorrect inhaler technique and cost remain a challenge to achieve good asthma control. Asthma education, including correct demonstration of inhaler, can potentially help to improve inhaler adherence.

Comparing the efficacy and safety of formoterol/budesonide pMDI versus its mono-components and other LABA/ICS in patients with asthma.

INTRODUCTION: Pressurised metered dose inhalers (pMDIs) are effective drug delivery devices prescribed in obstructive airway diseases due to their convenience, portability, ease of enabling multiple doses in a single formulation, and storage in any orientation. For the management of asthma, the fixed-dose combination of a long-acting ß2-agonist (LABA) and an inhaled corticosteroid (ICS) has been recommended by Global Initiative for Asthma guideline as a preferred treatment option for patients who are uncontrolled with only ICS doses. One of the available LABA/ICS combinations is the formoterol/budesonide (FB). AREAS COVERED: This article systematically reviews the efficacy and safety of the FB pMDI compared with the FB dry powder inhaler (DPI), individual mono-components (formoterol and budesonide) or salmeterol/fluticasone (SF) combination in the treatment of asthma among paediatric and adult patients. PubMed was searched with the string: ''((Budesonide) AND Formoterol) AND ((((pMDI) OR MDI) OR Pressurised Metered-dose inhaler) OR Metered-dose inhaler)'', in ALL fields. Screening of all the articles was done till February 2020. We have included 24 articles from the total of 142 hits received. CONCLUSIONS: The FB pMDI is efficacious for the long-term management of asthma in patients 6 years of age and above. It has been shown to improve lung function and asthma control, and to reduce daytime and night-time symptoms, the number of rescue medication doses and asthma exacerbations. It also showed rapid onset of bronchodilatory effect with a dose-response relationship that allows patients to utilise it as a Single Maintenance And Reliever Therapy (SMART) regimen.

The impact of textual and pictorial warnings on tumbac (waterpipe tobacco) boxes on the motivation and intention to quit waterpipe smoking in Lebanon: a cross-sectional study.

Few published studies have examined the impact of waterpipe tobacco pictorial health warnings worldwide but none of these papers assessed the motivation and intention to quit among Lebanese waterpipe smokers. To examine factors associated with the motivation and intention to quit waterpipe smoking (WS) in Lebanon, particularly the impact of textual vs. pictorial warnings on tumbac boxes. A cross-sectional study was conducted between January and May 2018, involving 520 participants. Having smokers at work (OR = 0.92) and increasing number of waterpipes per week (ORa = 0.94) were associated with decreased motivation to quit WS. Thinking that shocking images on tumbac packages would have more effect than textual warnings (ORa = 2.96) and those who would change the tumbac if the company decides to change the look of the box with shocking images about health damage (ORa = 1.98) were significantly associated with increased motivation to quit WS. Having a high motivation (ORa = 2.61), thinking that using shocking images on tumbac boxes can have more effect than textual warnings (ORa = 2.12), those who stopped smoking because of the warnings (ORa = 2.62), those who would choose pictorial warnings alone (ORa = 2.11), and both pictorial and textual warnings (ORa = 3.41) on tumbac packages were associated with higher intention to quit WS in two months. Pictorial and textual warnings on tumbac packs were associated with higher intention and motivation to stop WS. Public health education programs for this purpose seem warranted.

Validation of the St George's respiratory questionnaire and risks factors affecting the quality of life of Lebanese COPD and asthma patients.

Objective: We aimed to validate the Arabic version of the St George's Respiratory Questionnaire (SGRQ) for use in Lebanese Chronic obstructive pulmonary disease (COPD) and asthma patients and to identify risk factors that might affect the quality of life in these patients. Methods: COPD (n = 90) and asthma patients (n = 124) were recruited from the outpatient clinics of the Pulmonology department of a university hospital and a medical center in Beirut. They filled out a standardized questionnaire. The total SGRQ score and the component scores (symptoms, activity and impacts) were calculated. To confirm the SGRQ validity in the Lebanese population, factor analyses were applied for the whole sample, only asthma and only COPD patients, respectively. The associations between the total SGRQ score and FEV1% predicted, CCQ score and MRC scale were assessed. Multiple linear regression models were used to evaluate the association between the total SGRQ scores and the socio-demographics and the diseases risk factors. Results: COPD patients had a higher SGRQ total and subscales scores compared to asthma patients. A high Cronbach's alpha was found for the whole sample (0.802), only COPD patients (0.833) and only asthma patients (0.734). A significant negative correlation was found between FEV1% predicted and the total SGRQ scores. Occupational exposure, BMI and previous waterpipe smoking were among the factors that significantly and positively influenced a higher SGRQ score. Conclusions: The Lebanese version of the SGRQ emerges as a good health-related quality of life evaluative instrument that is reasonable to be used in COPD and asthma patients in Lebanon.

Validation of the mini pediatric asthma quality of life questionnaire and identification of risk factors affecting quality of life among Lebanese children.

BACKGROUND: Few studies used various scales to assess the QOL in Lebanon in general but none was specific to asthma. Our objective was to assess the asthma-related quality of life, using the mini Pediatric Asthma Quality of Life Questionnaire (PAQLQ), in Lebanese asthmatic children, check its validity compared to the original version, and identify clinical and sociodemographic risk factors that might affect these children's QOL. METHODS: This retrospective study included 300 children aged between 7-16 years (51.6% boys and 48.4% girls). To confirm the mini-PAQLQ questionnaire construct validity in the Lebanese population, an exploratory factor analysis was launched for the 13 items of the questionnaire, using the principal component analysis technique. Cronbach's alpha was recorded for reliability analysis. A multivariate analysis linear regression was carried out, taking the QOL score as the dependent variable. RESULTS: The correlation coefficients for factors 1 (symptoms and emotions) and 2 (activities) were similar to that of the original scale. High Cronbach's alphas were found for factor 1 (0.914), factor 2 (0.888), and the full scale (0.921). Uncontrolled asthma, the child's respiratory problems before the age of 2 years, and the presence of pets at home significantly decreased the children's asthma-related quality of life (Beta = -1.541; Beta = -6.846, and Beta = -5.364, respectively). CONCLUSION: We were able to validate the mini-PAQLQ among the Lebanese population. The identification of risk factors, some of which are amenable to intervention, especially uncontrolled asthma, could lead to an improvement in the asthmatic children's QOL.

Development of an asthma risk factors scale (ARFS) for risk assessment asthma screening in children.

BACKGROUND: The study objective was to create asthma risk factors scale (ARFS) score that would be correlated with the increased risk of asthma in Lebanese children. This scale would eventually be used both to identify children at risk and assess early diagnosis of asthma. METHODS: A case-control study (study 1) of 1276 children (976 controls and 300 cases) and a cross-sectional study (study 2) of 1000 children were conducted using a parental questionnaire. Children aged between 3 and 16 years were screened for possible enrollment. The ARFS was created by combining the following risk factors: child's exposure to pesticides, detergent mixing, alcohol, smoking and drug intake during pregnancy and breastfeeding, the actual paternal and maternal smoking status and history of asthma, and the types of food the child consumes. RESULTS: There was a significant increase in the risk assessment screening for asthma per 15 points increments of ARFS (p < 0.001 for trend). The score category 0-14.99 best-represented control individuals (88.8% controls), while a score higher than 45 represented asthmatic children best (98.4% asthmatics). The positive predictive value (disease positive/all positive by scale) came out as 94.02%, whereas the negative predictive value (disease negative/all negative by scale) was found to be 90.47%. These results were confirmed in the second study sample. CONCLUSION: The ARFS is a simple and easy-to-use tool, composed of 15 questions, for the clinician risk assessment of asthma in children, taking into account the environmental exposure, parental history of asthma and dietary habits of the child. Its value for asthma diagnosis remains to be confirmed in future prospective studies, especially in children with chronic respiratory symptoms.

Surfactant protein D multimerization and gene polymorphism in COPD and asthma.

BACKGROUND AND OBJECTIVE: A structural single nucleotide polymorphism rs721917 in the surfactant protein D (SP-D) gene, known as Met11Thr, was reported to influence the circulating levels and degree of multimerization of SP-D and was associated with both COPD and atopy in asthma. Moreover, disease-related processes are known to degrade multimerized SP-D, however, the degree of the protein degradation in these diseases is not clarified. We aimed to determine the distribution of multimerized (high molecular weight (HMW)) and non-multimerized (low molecular weight (LMW)) species of serum SP-D and their correlation with genetic polymorphisms and presence of disease in Lebanese COPD and asthmatic patients. METHODS: Serum SP-D levels were measured by ELISA in 88 COPD, 121 asthmatic patients and 223 controls. Randomly selected subjects were chosen for genotyping of rs721917 and multimerization studies. HMW and LMW SP-D were separated by gel permeation chromatography. RESULTS: Serum SP-D levels were significantly increased in patients with COPD, but not in asthmatic patients, when compared to controls. Met11Thr variation strongly affected serum SP-D levels and the degree of multimerization, but was not associated with COPD and asthma in the study. Remarkably, HMW/LMW serum SP-D ratio was significantly lower in Met11/Met11 COPD and asthmatic patients compared to controls. CONCLUSION: Collectively, non-multimerized species of serum SP-D were dominant in COPD and asthmatic patients suggesting that degradation of SP-D takes place to a significant degree in pulmonary disease. Assays that can separate SP-D proteolytic breakdown products or modified forms from naturally occurring SP-D trimers may result in optimal disease markers for pulmonary inflammatory diseases.

Predictors of Readiness to Quit Stages and Intention to Quit Cigarette Smoking in 2 and 6 Months in Lebanon.

BACKGROUND: We aimed at examining quitting behaviors among Lebanese cigarette smokers in order to clarify characteristics of adults who were more likely to intend to quit smoking. STUDY DESIGN: A cross-sectional study. METHODS: This study was conducted between March 2014 and March 2015, involving 382 patients randomly chosen from 5 outpatient clinics in 5 hospitals in Lebanon. A standardized questionnaire was completed including socio-demographic characteristics, smoking behavior, chronic respiratory symptoms, Fagerstrom scale, Mondor scale, packaging perception, quitting behavior and readiness to quit ladder. RESULTS: 40.8% of participants reported having higher stages of readiness to quit while 33% and 7.9% of them intended to quit in 2 and 6 months later, respectively. Higher stages of readiness to quit were associated with high motivation to quit smoking (ORa=1.98; P=0.007), chronic wheezing and real quit attempt duration of ≥ 1 month (ORa=2.35, P=0.020 and ORa=2.15, P=0.003, respectively). Highly motivated smokers (ORa=1.83, P=0.040), who would have changed their favorite pack due to the graphical warnings (ORa=2.11, P=0.010) and who had past quit attempt (ORa=4.39, P<0.001) had more intention to quit in 2 months. Having past quit attempts would increase the intention to quit in 6 months by 7.48 times (ORa=7.48, P=0.007). CONCLUSIONS: Significantly higher intentions to quit cigarette smoking were associated with a higher motivation and influenced by shocking images and health related warnings on tobacco boxes. We hope our results will initiate public health educational programs and interventions to surge the intention to quit cigarette smoking as the first step of quitting.

Motivation to quit smoking and acceptability of shocking warnings on cigarette packages in Lebanon.

INTRODUCTION: Health warnings on tobacco packages have been considered an essential pillar in filling the gap of knowledge and communicating the health risks of tobacco use to consumers. Our primary objective was to report the perception of smokers on the textual health warnings already appearing on tobacco packages in Lebanon versus shocking pictures about the health-related smoking consequences and to evaluate their impact on smoking behaviors and motivation. METHODS: A pilot cross-sectional study was undertaken between 2013 and 2015 in five hospitals in Lebanon. Participants answered a questionnaire inquiring about sociodemographic characteristics, chronic respiratory symptoms, smoking behavior and motivation to quit smoking. Only-text warning versus shocking pictures was shown to the smokers during the interview. RESULTS: Exactly 66% of the participants reported that they thought shocking pictorial warnings would hypothetically be more effective tools to reduce/quit tobacco consumption compared to only textual warnings. Also, 31.9% of the smokers who were motivated to stop smoking reported that they actually had stopped smoking for at least 1 month secondary to the textual warnings effects. A higher motivation to quit cigarette smoking was seen among the following groups of smokers: males (odds ratio [OR] =1.8, P=0.02), who had stopped smoking for at least 1 month during the last year due to textual warning (OR =2.79, P<0.001), who considered it very important to report health warning on cigarette packs (OR =1.92, P=0.01), who had chronic expectoration (OR =1.81, P=0.06) and who would change their favorite cigarette pack if they found shocking images on the pack (OR =1.95, P=0.004). CONCLUSION: Low-dependent smokers and highly motivated to quit smokers appeared to be more hypothetically susceptible to shocking pictorial warnings. Motivation to quit was associated with sensitivity to warnings, but not with the presence of all chronic respiratory symptoms.

Validation of asthma control questionnaire and risk factors affecting uncontrolled asthma among the Lebanese children's population.

OBJECTIVES: To validate the Arabic version of the Asthma Control Test (ACT) in asthmatic children in Lebanon and identify risk factors that might affect asthma control in these children. METHODS: This study, conducted between December 2015 and April 2016, included 300 children. RESULTS: A high Cronbach's alpha was found for the full scale (0.959). The correlation factors between each item of the ACT scale and the whole scale ranged between 0.710 and 0.775(p < 0.001 for all items). Low mother's educational level as well as the history of asthma in the mother and the father would significantly increase the risk of uncontrolled asthma (p = 0.001; Beta = 1.862; p < 0.001; Beta = 3.534; p < 0.001; Beta = 1.885respectively). Cigarette smoking during breastfeeding and waterpipe smoking by the mother during pregnancy were both significantly associated with uncontrolled asthma (p = 0.005; Beta = 2.105 and p = 0.041; Beta = 2.325 respectively). The high mother's level of education was significantly associated with more asthma control (p = 0.008; Beta = -0.715). CONCLUSION: The Arabic version of the asthma control questionnaire is a valid tool to use in pediatric patients in the Lebanese population to assess asthma control. Waterpipe smoking during pregnancy and cigarette smoking during breastfeeding, as well as the lower education level are risk factors for uncontrolled asthma. Spreading awareness among health care professionals, as well as reinforcing health education seem to be an important step toward a better asthma control.

Association between Caregiver Exposure to Toxics during Pregnancy and Childhood-onset Asthma: A Case-control Study.

The aim of this study was to evaluate the associations between caregiver-reported use of medications, alcohol, cigarette and/or waterpipe (WP), and exposure to pesticides/detergents during pregnancy with childhood-onset asthma. The study design consisted of a case-control study, conducted between December 2015 and April 2016, recruited 1503 children, aged between 3-16 years old. A questionnaire assessed the sociodemographic characteristics (age, gender, education level of both parents), the family history of asthma, and other known risk factors of asthma (heating system at home, child history of recurrent otitis, humidity in the house, child went to a daycare, smoking and drinking alcohol during pregnancy, exposure to pesticides and detergents). The multivariate analysis showed that children living in North and South Lebanon and the children living in areas where pesticides are frequently used had an increased risk of asthma (ORa=1.625, CI 1.034-2.554, p=0.035, ORa=13.65, CI 3.698-50.385; p<0.001 and ORa=3.307, CI 1.848-5.918, p<0.001 respectively). Smoking WP during pregnancy and cigarette during lactation would increase the risk of asthma in children (ORa=6.11; CI 1.244-30.008; p=0.026 and ORa=3.44; CI 1.024-11.554; p=0.046 respectively). We conclude that asthma may originate from the environmental exposure to toxics such as pesticides and tobacco (cigarettes and WP) or to alcohol and prescribed medications during pregnancy and lactation. Spreading awareness by health professionals about these preventable causes can help educate the parents and children to prevent asthma and its exacerbation.

Surfactant protein D, a clinical biomarker for chronic obstructive pulmonary disease with excellent discriminant values.

Biological markers can help to better identify a disease or refine its diagnosis. In the present study, the association between surfactant protein D (SP-D) and chronic obstructive pulmonary disease (COPD) was studied among subjects consulting for respiratory diseases or symptoms and was compared with C-reactive protein (CRP) and fibrinogen. A further aim of this study was to identify the optimal cut-off point of SP-D able to discriminate COPD patients. A case-control study including 90 COPD patients, 124 asthma patients and 180 controls was conducted. Standardized questionnaires were administered and lung function tests were performed. Biological markers were measured in blood samples according to standardized procedures. The association between SP-D and COPD was investigated using logistic regression models. Receiver-operating characteristic curves were used for threshold identification. SP-D levels above the median value were positively associated with COPD [adjusted odds ratio (OR)=3.86, 95% confidence interval (CI): 1.51-9.85, P=0.005). No associations with COPD or asthma were found for CRP or fibrinogen levels. Scores for COPD diagnosis in all COPD patients or ever-smoker COPD patients were identified (sensitivity, 76.4 and 77.8%; specificity, 89.3 and 88.5%, respectively). The results indicate that SP-D can differentiate COPD from other respiratory symptoms or diseases. Used with socio-demographic characteristics and respiratory symptoms, SP-D is able to discriminate COPD patients from controls, particularly among smokers.