Pharmacogenomics in Lebanon: current status, challenges and opportunities.

Pharmacogenomics (PGx) research and applications are of utmost relevance in Lebanon considering its population genetic diversity. Moreover, as a country with regional leadership in medicine and higher education, Lebanon holds a strong potential in contributing to PGx research and clinical implementation. In this manuscript, we first review and evaluate the available PGx research conducted in Lebanon, then describe the current status of PGx practice in Lebanon while reflecting on the local and regional challenges, and highlighting areas for action, and opportunities to move forward. We specifically expand on the status of PGx at the American University of Beirut Faculty of Medicine and Medical Center as a case study and guide for the further development of local and regional comprehensive PGx research, teaching, and clinical implementation programs. We also delve into the status of PGx knowledge and education, and prospects for further advancement such as with online courses and certificates.

Overuse of antibiotics for urinary tract infections in pregnant refugees, Lebanon.

Objective: To determine whether adding urine culture to urinary tract infection diagnosis in pregnant women from refugee camps in Lebanon reduced unnecessary antibiotic use. Methods: We conducted a prospective, cross-sectional study between April and June 2022 involving pregnant women attending a Médecins Sans Frontières sexual reproductive health clinic in south Beirut. Women with two positive urine dipstick tests (i.e. a suspected urinary tract infection) provided urine samples for culture. Bacterial identification and antimicrobial sensitivity testing were conducted following European Committee on Antimicrobial Susceptibility Testing guidelines. We compared the characteristics of women with positive and negative urine culture findings and we calculated the proportion of antibiotics overprescribed or inappropriately used. We also estimated the cost of adding urine culture to the diagnostic algorithm. Findings: The study included 449 pregnant women with suspected urinary tract infections: 18.0% (81/449) had positive urine culture findings. If antibiotics were administered following urine dipstick results alone, 368 women would have received antibiotics unnecessarily: an overprescription rate of 82% (368/449). If administration was based on urine culture findings plus urinary tract infection symptoms, 144 of 368 women with negative urine culture findings would have received antibiotics unnecessarily: an overprescription rate of 39.1% (144/368). The additional cost of urine culture was 0.48 euros per woman. Conclusion: A high proportion of pregnant women with suspected urinary tract infections from refugee camps unnecessarily received antibiotics. Including urine culture in diagnosis, which is affordable in Lebanon, would greatly reduce antibiotic overprescription. Similar approaches could be adopted in other regions where microbiology laboratories are accessible.

A clinicopathological study about the epidemiology of granulosa cell tumors in Lebanon.

BACKGROUND: Granulosa Cell Tumors (GCT) are considered the most frequent type of sex-cord stromal tumors. These tumors constitute 3-6% of neoplasms of the ovaries. GCTs are divided into 2 types: Juvenile GCT (JGCT) and Adult GCT (AGCT). Most patients are diagnosed early in the course of the disease and tend to have a favorable prognosis. In the surgical treatment of GCT, two main factors play role in the determination of feasibility of the surgery: age and tumor stage. METHODS: A retrospective study was conducted on 65 consecutive female patients diagnosed with ovarian GCT at different hospitals across Lebanon who were referred to the National Institute of Pathology, Beirut-Lebanon, between January 2000 and January 2020. Then, they were divided according to types: adult versus juvenile type. Statistical analysis was carried out using Stata, version 16. RESULTS: The incidence of GCT in a Lebanese population was 16.2 per million per year. The mean age of the studied population was 55.6 years. AGCT was the most common with a prevalence of 91% versus 19% for JGCT. Also, inhibine (the most important immunomarker) was found in 77.2% of adult cases. High mitotic index and high tumor size which are predictors for poor prognosis were respectively 20% and 36.9%. Concerning the histopathological features, Grooved nuclei and Exner bodies were less frequently observed in juvenile type (16.7% for both) compared to adult type (36.9%). Most patients with GCT were diagnosed in the early course of disease mainly due to the manifestation of the symptoms as abdominal pain, postmenopausal bleeding or intermenstrual bleeding, and the good diagnosis and screening practices in Lebanon. Regarding the recurrent cases, a significant correlation with high mitotic index (76.9%), high tumor size (92.3%) and advanced stage (46% for stage 3 and 46% for stage 4) was found with a p < 0.05. CONCLUSIONS: The incidence of GCT in the Lebanese population is 16.2 per million per year. The majority of patients with GCT in Lebanon are of Adult type representing around 90% of cases. Older age, high mitotic index and big tumor size are predictors for poor outcomes.

Effect of young age (below 40 years) on oncologic outcomes in Lebanese patients with breast cancer: a matched cohort study.

BACKGROUND: Developing countries have a significantly higher incidence of breast cancer in patients younger than 40 years as compared to developed countries. This study aimed to examine if young age at diagnosis is an independent prognostic factor for worse survival outcomes in breast cancer as well as the effect of age on Disease-free survival (DFS) and local recurrence free survival (LRFS) after adjusting for various tumor characteristics, local and systemic treatments. METHODS: This is a secondary analysis of prospective cohort of patients from two existing databases. We identified patients with breast cancer aged 40 years or less and we matched them to those older than 40 years. We also matched based on stage and molecular subtypes. In cohort 1, we matched at a ratio of 1:1, while in cohort 2 we matched at a ratio of 1:3. RESULTS: In cohort 1, Disease-free survival (DFS) at 5 years was significantly shorter for those younger than 40 years (75.6% and 92.7% respectively; p < 0.03). On multivariate analysis, only chemotherapy was found to be significant, while age was not found to be an independent predictor of prognosis. Local recurrence free survival at 5 years was similar between both age categories. Only hormonal therapy is a significant predictor for LRFS at 5 years. In the second cohort, DFS and LRFS at 3 years were similar between those younger and those older than 40 years. On multivariate analysis, no factor including age was found to be an independent predictor of prognosis. CONCLUSION: Data in the literature is controversial on the effect of young age on breast cancer prognosis. Our findings could not demonstrate that age is an independent prognostic factor in our population. There is a need for outcomes from larger, prospective series that have longer follow-ups and more data from our region.

Diagnostic and treatment patterns in urinary and genital tract infections: insights from a referral clinic in Beirut, Lebanon.

BACKGROUND: Urinary Tract Infections (UTIs) and Genital Tract Infections (GTIs) are common yet serious health concerns. Precise diagnosis is crucial due to the potential severe consequences of misdiagnosis. This study aims to distinguish between UTIs and GTIs, highlighting the importance of accurate differentiation. MATERIALS AND METHODS: The study encompassed 294 patients, categorized into 4 groups: Group GNI (no infection, N = 57), Group GUI (urinary infection, N = 52), Group GGI (genital infection, N = 139), and Group GGUI (both infections, N = 46). Methods included patient interviews, clinical examinations, and laboratory tests such as urine and vaginal swab cultures. RESULTS: The investigation revealed no significant differences in age, BMI, residency, or nationality across groups. However, socioeconomic status varied, with Group GNI having the lowest proportion of low socioeconomic status. In obstetrical characteristics, non-pregnancy rates were higher in Groups GUI and GGUI, with GGUI showing a notably higher abortion rate. Symptom analysis indicated lower symptom prevalence in Group GNI, with pain, itching, pruritus, and vaginal discharge being less frequent, suggesting a link between infection presence and symptom severity. Treatment patterns showed higher usage of ciprofloxacin, antifungals, and vaginal tablets in Groups GUI and GGUI. Laboratory findings highlighted significant Leucocyte Esterase presence and variations in WBC and RBC counts, particularly in Group GGUI. CONCLUSION: The study emphasizes the need for advanced diagnostic techniques, especially those focusing on individual microbial patterns, to enhance UGTI diagnosis. Variations in symptom presentation and treatment across groups underline the necessity for personalized diagnostic and treatment strategies.

Epidemiology of Breast, Corpus Uteri, and Ovarian Cancers in Lebanon With Emphasis on Breast Cancer Incidence Trends and Risk Factors Compared to Regional and Global Rates.

OBJECTIVES: This study explores the incidence and trends of breast (Bca), corpus uteri (CUca), and ovarian (Oca) cancer in Lebanon, a Middle Eastern country. It compares the Bca rates to regional and global ones and discusses Bca risk factors in Lebanon. INTRODUCTION: Globally, Bca is the premier cause of cancer morbidity and mortality in women. METHODS: Data on female Bca, CUca, and Oca published by the Lebanese national cancer registry were obtained (ie, for the years of 2005 to 2016). The age-standardized incidence rates (ASIRw) and age-specific rates per 100,000 female population were computed. RESULTS: From 2005 to 2016, Bca, Oca, and CUca ranked first, sixth, and seventh, respectively, for cancer incidence among women in Lebanon. Bca alone accounted for 39.4% of all new female cancer cases. The ASIRw increased significantly for Bca and CUca (APC: 3.60 and 3.73, P < .05) but not for Oca (APC: 1.27, P > .05). The Bca ASIRw (per 100,000) increased significantly from 71.0 in 2005 to 115.6 in 2013 (P < .05), then decreased steadily but non-significantly to reach 96.8 in 2016 (P > .05). Lebanon's Bca ASIRw is comparable to developed countries. This may reflect altered sociological and reproductive patterns as the country transitions from regional to global trends. The five-year age-specific rates analysis revealed that Bca rates rose steeply from 35-39 to 50-54, dropped slightly between 55 and 64, then rose till 75+. The five-year age-specific rates between 35 and 54 among Lebanese women were amongst the highest worldwide from 2008 to 2012, even higher than the rates in Belgium, which had the highest ASIRw of Bca worldwide in 2020. CONCLUSION: Lebanon's Bca ASIRw is among the highest globally. It's important to investigate the contributing factors and develop a national Bca control strategy. This study supports the national recommendation in initiating Bca screening at age 40 for women.

Building a maternal and child cohort amidst Lebanon's socioeconomic collapse: preliminary results and navigating research challenges.

The impact of conflict and crisis on maternal and child health underscores the need for reliable research in vulnerable populations. Lebanon, amidst ongoing economic collapse, political instability, and healthcare system strain, offers a case study for exploring these impacts, particularly on preterm babies and their development. This study aims to assess the feasibility of establishing a prospective cohort of mothers and their full-term and preterm babies in Lebanon, examining the association between social determinants, preterm birth, and developmental outcomes amidst the nation's multifaceted crises. The planned cohort involves 50 full-term and 50 preterm mother-baby pairs recruited at birth and followed up to 9-12 months post-birth. Data collection spans social determinants, perceived stress, social support, quality of life, and developmental assessments. Challenges in recruitment, follow-up, and data collection in the context of Lebanon's socio-political and economic turmoil are evaluated, alongside ethical considerations for research in vulnerable populations. Preliminary findings highlight substantial recruitment and follow-up challenges, notably due to population mobility, economic instability, and healthcare access issues. Despite these obstacles, 113 mother-baby pairs have been recruited. Early analysis reveals significant stress and reduced quality of life among mothers, particularly those with preterm infants, against a backdrop of declining birth rates and healthcare worker exodus. Conducting research in crisis settings like Lebanon presents unique methodological and ethical challenges but remains crucial for understanding and improving health outcomes in vulnerable populations. The study underscores the importance of adaptable research designs and ethical diligence in crisis research, highlighting the need for interventions tailored to these contexts. Establishing a mother and child cohort in Lebanon's crisis-ridden setting is faced with many challenges but is essential for guiding future interventions. Research in such contexts is needed to address health disparities and supporting vulnerable populations, emphasizing the need for dedicated funding and innovative research approaches in times of crisis.

Patterns and predictors of positive multiplex polymerase chain reaction respiratory panel among patients with acute respiratory infections in a single center in Lebanon.

BACKGROUND: Infectious agents associated with community-acquired acute respiratory infections (ARIs) remain understudied in Lebanon. We aim to assess the microbiological profiles of ARIs by employing polymerase chain reaction (PCR) and identifying predictors of positive PCR results among patients admitted for ARI. METHODS AND RESULTS: We conducted a retrospective single-center study at the American University of Beirut Medical Center, including all respiratory PCR panels performed on pediatric (< 18) and adult (≥ 18) patients presenting with an ARI from January 2015 to March 2018, prior to the onset of the COVID-19 pandemic. We aimed to identify the epidemiological patterns of ARIs and the factors associated with positive PCRs in both adult and pediatric patients. Among 281 respiratory PCRs, 168 (59.7%) were positive for at least one pathogen, with 54.1% positive PCR for viruses, 7.8% for bacteria species, and 3.9% with virus-bacteria codetection. Almost 60% of the patients received antibiotics prior to PCR testing. PCR panels yielded more positive results in pediatric patients than in adults (P = 0.005). Bacterial detection was more common in adults compared to pediatrics (P < 0.001). The most common organism recovered in the entire population was Human Rhinovirus (RhV) (18.5%). Patients with pleural effusion on chest CT were less likely to have a positive PCR (95% Cl: 0.22-0.99). On multivariate analysis, pediatric age group (P < 0.001), stem cell transplant (P = 0.006), fever (P = 0.03) and UTRI symptoms (P = 0.004) were all predictive of a positive viral PCR. CONCLUSION: Understanding the local epidemiology of ARI is crucial for proper antimicrobial stewardship. The identification of factors associated with positive respiratory PCR enhances our understanding of clinical characteristics and potential predictors of viral detection in our population.

Predictive factors and quality of life assessment among patients with spinal cord injury in the Middle East: a systematic review.

PURPOSE: Spinal cord injury (SCI) is impairment of the spinal cord that adversely affects patients' health and quality of life (QoL). The aim of the study was to assess the quality of life (QoL) and related factors in patients with traumatic spinal cord injury in Middle Eastern countries. METHODS: PubMed, Ovid Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EBSCOhost, psycINFO, and Google Scholar were systematically searched for eligible studies published in peer-reviewed journals up till October 2023. RESULTS: Out of 1060 papers found in the literature, only 18 studies from Iran, Lebanon, and Turkey met the inclusion criteria. The majority of the studies employed the SF-36 scale to assess for QoL. In general, all SCI patients had reduced QoL scores when compared to the healthy population. Some of the factors such as age, education level, the level of injury, time since injury onset, marriage, and job opportunities were correlated with SCI subjects QoL. Our papers were assessed and found to be of both good and high quality. CONCLUSION: This review emphasizes the significant shortage of QoL studies among SCI patients in the Middle East countries and highlights the importance of improving the QoL of this marginalized population. This work should enhance the governments to establish rehabilitation centers, social and economic support systems, and mental health services to diminish complications arising from SCI.

Moderating effect of self-esteem between perfectionism and avoidant restrictive food intake disorder among Lebanese adults.

BACKGROUND: Avoidant Restrictive Food Intake Disorder (ARFID) is a new diagnosis added to the DSM-5 characterized by pathological eating habits without body image disturbances. Previous findings demonstrated a general association between high levels of perfectionism and low levels of self-esteem in association with general eating disorders. However, research is scant when it comes to ARFID specifically. Subsequently, although self-esteem is seen to moderate the association between perfectionism and general eating disorders, this research study aims to explore the same moderation but with ARFID specifically. METHODS: For this study, 515 Lebanese adults from the general Lebanese population were recruited from all over Lebanon, 60.1% of which were females. The Arabic version of the Big Three Perfectionism Scale- Short Form (BTPS-SF) was used to measure self-critical, rigid and narcissistic perfectionism; the Avoidant/Restrictive Food Intake Disorder screen (NIAS) was used to score the ARFID variable; the Arabic-Single Item Self-Esteem (A-SISE) was the scale used to measure self-esteem. RESULTS: Across the different perfectionism types, self-esteem was seen to moderate the association between narcissistic perfectionism and ARFID (Beta = - 0.22; p =.006). At low (Beta = 0.77; p <.001), moderate (Beta = 0.56; p <.001) and high (Beta = 0.36; p =.001) levels of self-esteem, higher narcissistic perfectionism was significantly associated with higher ARFID scores. CONCLUSION: This study brought to light some crucial clinical implications that highlight the need for interventions that help in the enhancement of self-esteem in patients with high perfectionism and ARFID. This study suggests that clinicians and healthcare professionals should focus more on risk factors influencing the development and maintenance of ARFID-like symptoms.

Psychometric properties of the Arabic versions of the long (27 items) and short (13 items) forms of the interpersonal mindfulness scale (IMS).

BACKGROUND: There is a lack of measures and data on interpersonal mindfulness from non-Western cultures, which can hinder advances in our understanding of the construct, its conceptual representation, and its effects on human connection and relationships within different cultural settings. To fill this gap and help spark future research in this area in the Arab world, the current study aimed to examine the psychometric properties of an Arabic translation of the 27-item and the 13-item versions of the interpersonal Mindfulness Scale (IMS) in a sample of Arabic-speaking adolescents from the general population. METHODS: A web-based survey was conducted in a sample of 527 Lebanese community adolescents (Mean age = 15.73 ± 1.81 years; 56% females). The IMS was translated from English into Arabic using the forward-backward translation method. Participants completed the long and short forms of the IMS, as well as the Buss-Perry Aggression Questionnaire-Short Form (BPAQ-SF), and the 5-item Brief Irritability Test. RESULTS: Confirmatory factor analyses provided support to the four-factor structure of both the 27-item and the 13-item IMS (i.e., Presence, Awareness of Self and Others, Nonjudgmental Acceptance, and Nonreactivity). The original and the short form versions of the IMS yielded excellent internal consistency in our sample, with a Cronbach's α coefficients of 0.95 and 0.90, and McDonald's omega coefficients of 0.95 and 0.90, respectively. Multigroup comparisons suggested the factorial invariance of the Arabic 27-item and 13-item IMS between male and female participants at the metric, configural, and scalar levels. Finally, the concurrent validity of both full-length and short form of the IMS appeared to be good and comparable, as attested by patterns of correlations in expected directions with outcome variables (i.e., aggression, anger, hostility, and irritability). CONCLUSION: The present findings provide support for the good psychometric qualities of the Arabic translation of the IMS in both long and short forms, suggesting that these scales are suitable for use to measure interpersonal mindfulness in Arabic-speaking youth, at least in Lebanon. We expect that the IMS, in particular its shortest form, will prompt more systematic investigation of interpersonal mindfulness in the Arabic-speaking populations, especially with regard to enhancing healthy communications with others and building effective social relationships.

Translation and validation to the Arabic language version of the climate change anxiety scale (CCAS).

BACKGROUND: The Arab world is one of the global regions the most directly concerned by, and suffering from climate change's adverse consequences. As such, there appears to be a strong need for an understanding of how Arab people may emotionally respond to climate change. Providing valid and reliable measures of climate change anxiety (CCA) can help gain a clear overview of the situation in Arab countries, and allow to intervene timely and effectively to mitigate any adverse effects on Arab people's mental health. To this end, the present study sought to validate the Arabic language version of the Climate Change Anxiety Scale (CCAS) in a sample of native Arabic-speaking adults from the general population of Lebanon. METHODS: This study adopted a cross-sectional approach and enrolled 763 adults between July and September 2023. RESULTS: A confirmatory analysis of the one-factor model showed poor fit indices as follows: CFI = 0.90, GFI = 0.83, SRMR = 0.048 and RMSEA 0.131 [90% CI 0.123, 0.138). The two-factor model showed a satisfactory fit with a high CFI of and a GFI of 0.91 and a SRMR of 0.04 and RMSEA of 0.05 [90% CI 0.04, 0.06]. Both McDonald's omega and Cronbach alpha values were high for the overall CCAS score (α = 0.96 and ω = 0.96) in the whole sample. Configural, metric and scalar invariance across gender was demonstrated. No significant difference was found between males and females in terms of total CCAS scores (24.53 ± 10.59 vs. 26.03 ± 11.17, t(761) = -1.82, p = .069). Higher CCA, functional impairment and cognitive impairment scores were significantly associated with higher depression, anxiety and stress. CONCLUSION: The reliability and validity of the CCAS in its Arabic version were proven. The availability of this self-report measure could offer a chance to assess CCA among Adults speaking Arabic, and to spread its future use for screening and research purposes.

Validation and optimal cut-off score of the World Health Organization Well-being Index (WHO-5) as a screening tool for depression among patients with schizophrenia.

BACKGROUND: The utility of the World Health Organization Wellbeing Index (WHO-5) as rapid screening tool for depression has not yet been researched in the context of schizophrenia. The goals of this study were twofold: (1) to test the psychometric properties of the WHO-5 in a sample of Arabic-speaking patients with schizophrenia from Lebanon, with particular emphasis on validating the WHO-5 as a screening tool for wellbeing and depression in patients with schizophrenia; and (2) to determine the optimal cut-off point to identify schizophrenia patients with depression. METHODS: Chronic, remitted patients with schizophrenia took part in this cross-sectional study between August and October 2023 (n = 117; mean age of 57.86 ± 10.88 years and 63.3% males). The Calgary Depression Scale for Schizophrenia (CDSS) was included as index of validity. For the validation of the WHO-5 scale, we performed a confirmatory factor analysis (CFA) using the original structure of the scale. To assess the discriminatory validity of the Arabic version of the WHO-5 as a screening tool for depression, we conducted a Receiver operating characteristic (ROC) curve analysis, taking the WHO-5 reversed score against the dichotomized CDSS score at a cut off value of 6. RESULTS: The results of CFA supported the originally proposed unidimensional structure of the measure, with good internal consistency reliability (α = 0.80), concurrent validity, and cross-sex measurement invariance. The WHO-5 showed a sensitivity of 0.8 and a specificity of 0.7 in the detection of depression with a cut-off point of 9.5. The validity of the WHO-5 as a screening tool for depression was supported by the excellent discrimination AUC value of 0.838. Based on this WHO-5 cut-off value, 42.6% of the patients were screened as having a depression. CONCLUSION: The study contributes to the field by showing that the WHO-5 is a concise and convenient self-report measure for quickly screening and monitoring depressive symptoms in patients with schizophrenia. It is therefore highly recommended to apply this cut-off point for screening and follow-up assessments. The current findings will hopefully encourage clinicians and researchers working in Arab settings, who are often confronted with significant time and resource constraints, to start using the WHO-5 to aid their efforts in mitigating depression in this vulnerable population and fostering research in this under-researched area.

Psychometric properties of an Arabic translation of the meaning in life scale in a sample of young adults.

BACKGROUND: Young adults are in a constant phase of realizing their meaning in life while being in a constant pursuit of meaning. Meaning in life is a subjective, personal construct related to the perception of one's own life. Considering that there are no measures that study this construct within the Arab context, this study aimed to examine the psychometric properties of an Arabic translation of the Meaning in Life Questionnaire (MLQ) in the Lebanese context with a sample of young adults. METHODS: A sample of 684 Lebanese young adults was recruited for this study, having a mean age of 21.74 years, 65.6% of which were females. Through an online questionnaire, participants were requested to complete the Meaning in Life Questionnaire (MLQ), Depression, Anxiety and Stress Scale (DASS-8) and the Oviedo Grit Scale (EGO). RESULTS: CFA indicated that fit of the original bi-dimensional model of MLQ scores was inadequate. Items 9 and 10 cross-loaded to both MLQ factors. After removal of those 2 items, the final model displayed good fit indices. Reliability was good for the Search (ω = 0.89 / α = 0.89) and Presence (ω = 0.88 / α = 0.87) subscales. Additionally, across three levels of gender invariance (Configural, Metric and Scalar), no significant gender-based distinctions were observed in the MLQ scores. The Search subscale was significantly and positively associated with higher GRIT but not psychological distress, whereas the Presence subscale was significantly associated with higher GRIT and lower psychological distress. CONCLUSION: The results of this study contribute to the psychometric reliability and validity of the Arabic version of the MLQ and makes it available for dissemination among young adults within the Arab context. This allows for the implementation of new research that target construct of meaning in life, allowing for the accessibility of interventions that aim to foster the presence of and search for meaning in the lives of young adults within the Arab nations.

Psychometric properties of the Arabic version of the Nightmares Distress Questionnaire (NDQ-AV) in a community sample of adolescents.

BACKGROUND: The Nightmare Distress Questionnaire (NDQ), known and commonly used for its adequate psychometric properties, is the most widely used instrument for the measurement of nightmare distress. This study aimed to assess the psychometric properties of a newly translated Arabic version of the Nightmare Distress Questionnaire (NDQ-AV). METHODS: A total of 546 Lebanese adolescents was recruited for this study and completed the NDQ-AV, the Insomnia Severity Index (ISI), and the eight-item Depression, Anxiety and Stress Scale (DASS-8). RESULTS: The results of the exploratory factor analysis (EFA) and the confirmatory factor analysis (CFA) supported both a one-factor model and a two-factor model of the NDQ-AV, with the latter consisting of seven items within both factors. The first factor was referred to as the "general nightmare distress and coping" while the second was named "nightmare impact and perception". The reliability of the scale was excellent (α = 0.930 and ω = 0.915). Moreover, measurement invariance was shown across gender, demonstrating that this measure performs consistently for both men and women. Additionally, the NDQ-AV scores exhibited excellent reliability alongside factorial and concurrent validity. CONCLUSION: In conclusion, these results support the psychometric validity of the Arabic version of the NDQ. The availability of the NDQ-AV is expected to facilitate the understanding of nightmare distress within the Lebanese context.

Centring participant experience: a realist evaluation of a menstruator-friendly facility design project in a refugee settlement, Lebanon.

INTRODUCTION: Menstrual health in humanitarian contexts is a neglected topic. Its taboo nature presents difficulties for participants in menstrual health projects in these particularly challenging settings. Namely, their experiences may be concealed or overlooked in projects that are typically outcome focused. Realist Evaluation is a useful method to unearth and explore the hidden mechanisms and their causes, which lead to positive or negative participant experiences. The authors have applied this approach to a robust humanitarian menstrual health project to explore how to centre the emotional wellbeing of participants at all stages: prior to, during, and post-participation. STUDY SETTING: The project studied was led by the International Federation of Red Cross and Red Crescent Societies who piloted their adaptable manual for menstruator-friendly water, sanitation and hygiene (WaSH) facility design in humanitarian contexts. It was conducted by the Lebanese Red Cross in an informal tented settlement hosting Syrian refugees in Qaa, Lebanon. METHODS: The authors collected interview and focus group data on the contextual factors and processes within the project from nine project staff and 16 settlement inhabitants. They used a realist process of theory development, testing, and consolidation to understand how and under what circumstances the project inputs affected participants' wellbeing. RESULTS: The contextual factors and causal mechanisms promoting participant experience comprised individual (choices influencing and experience during participation), interpersonal (group dynamics and the role of non-menstruators), and organisational (expertise and knowledge, relationship to participants and cultural differences) factors. IMPLICATIONS: The research uses a case study from a renowned humanitarian organisation who provided a well-delivered project in a conducive environment to explore the mechanisms and contexts that can promote wider learning and refine understanding and programming in this under-researched and -theorised space. Specifically, it informs which contextual factors and project inputs must be present within a menstrual health project to ensure participant satisfaction whilst efficiently delivering well-designed menstruator-friendly WaSH facilities.

Prostate cancer presentation and management in the Middle East.

BACKGROUND: Although prostate cancer is a prevalent malignancy worldwide, its clinical presentation and management in the Middle East are not well-documented. This study aims to provide insights into the initial clinical presentation and management of prostate cancer in this region. METHODS: A retrospective review was conducted on seven institutional databases from six Middle Eastern countries, including Türkiye, Lebanon, Iraq, Syria, Bahrain, and Jordan, to identify patients diagnosed with prostate cancer in 2021. Descriptive analysis was performed on the collected data to provide an overview of the demographic, clinical, and treatment variables. RESULTS: A total of 1,136 patients were identified with a median age of 70 (range, 50-84). Most patients (78%) received their prostate cancer diagnosis after presenting with symptoms, as opposed to routine PSA screening. At the time of diagnosis, 35% of men had clinical T3 or T4 disease, 54% with Stage IV disease and 50% with Gleason score ≥ 8. Regarding treatment, 20% of non-metastatic and 22% of metastatic patients received no treatment. CONCLUSION: Most men in this study sought prostate cancer evaluation due to symptoms and were subsequently diagnosed with advanced-stage disease, providing a foundation for future research aimed at understanding the underlying factors behind the observed trends and enabling informed interventions.

Rationalizing the Influence of Co-Design on Distress, Clinical Decision-Making and Disease Self-Management of Cancer Patients-as-Partners: A Quasi-Experimental Study.

INTRODUCTION: Cancer is regarded as a major worldwide burden. Patient distress has been linked to disease progression. Studies show that engagement strategies affect clinical decision-making and patient outcomes. The optimal engagement method is a partnership that integrates the patient's expertise into the comprehensive co-design of the healthcare system. OBJECTIVES: This is the first study to investigate cancer patient-as-partner experience and its impact on distress levels, decision-making and self-management. METHODS: It is a quantitative and quasi-experimental study that adopted a partnership committee at a Lebanese hospital. A stratified random sampling approach was used, and data were collected by self-administered questionnaires. We utilized the standardized distress thermometer and PPEET. RESULTS: We recruited 100 patient partners. Cancer patients-as-partners had optimal engagement experience in QI projects (mean = 4; SD = 0.4). The main partnership benefit was improved hospitalization experience (49%). Almost half of PP reported no challenges faced (49%). Recommendations for improvement were training (19%), team dynamics management (12%) and proper time allocation (7%). The distress level post-partnership was significantly reduced (t = 12.57, p < 0.0001). This study highlights the importance of partnership and its ability to influence shared decision-making preference [χ2(2) = 13.81, p = 0.025] and self-management practices [F(3, 11.87) = 7.294, p = 0.005]. CONCLUSION: Research findings suggest that partners from disadvantaged groups can have optimal partnership experience. A partnership model of care can shape the healthcare system into a people-oriented culture. Further research is needed to explore diverse PP engagement methodologies and their effect on organizational development. PATIENT OR PUBLIC CONTRIBUTION: Patients and family members were engaged in the co-design of the study methodology, especially the modification of a research instrument. Patient partners with lived experience were involved in the patient partnership committee as core members to improve healthcare system design and evaluation.

Adhesive and biofilm-forming Candida glabrata Lebanese hospital isolates harbour mutations in subtelomeric silencers and adhesins.

BACKGROUND: The prevalence of Candida glabrata healthcare-associated infections is on the rise worldwide and in Lebanon, Candida glabrata infections are difficult to treat as a result of their resistance to azole antifungals and their ability to form biofilms. OBJECTIVES: The first objective of this study was to quantify biofilm biomass in the most virulent C. glabrata isolates detected in a Lebanese hospital. In addition, other pathogenicity attributes were evaluated. The second objective was to identify the mechanisms of azole resistance in those isolates. METHODS: A mouse model of disseminated systemic infection was developed to evaluate the degree of virulence of 41 azole-resistant C. glabrata collected from a Lebanese hospital. The most virulent isolates were further evaluated alongside an isolate having attenuated virulence and a reference strain for comparative purposes. A DNA-sequencing approach was adopted to detect single nucleotide polymorphisms (SNPs) leading to amino acid changes in proteins involved in azole resistance and biofilm formation. This genomic approach was supported by several phenotypic assays. RESULTS: All chosen virulent isolates exhibited increased adhesion and biofilm biomass compared to the isolate having attenuated virulence. The amino acid substitutions D679E and I739N detected in the subtelomeric silencer Sir3 are potentially involved- in increased adhesion. In all isolates, amino acid substitutions were detected in the ATP-binding cassette transporters Cdr1 and Pdh1 and their transcriptional regulator Pdr1. CONCLUSIONS: In summary, increased adhesion led to stable biofilm formation since mutated Sir3 could de-repress adhesins, while decreased azole susceptibility could result from mutations in Cdr1, Pdh1 and Pdr1.