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.

Transcatheter mitral-valve repair for functional mitral regurgitation data from the real-life in comparison with landmark randomized trials

Background

Publication of COAPT and MITRA-FR trials on the use of transcatheter mitral-valve repair (TMVR) for functional mitral regurgitation (MR) in 2018, has raised many questions due to their divergent results despite having similar objectives.

Purpose

To investigate the characteristics and outcomes of patients from real-life data who underwent TMVR for functional MR, in comparison with the two landmark trials.

Methods

A meta-analysis was performed according to Cochrane Handbook for Systematic Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. A comprehensive systematic literature search was conducted to identify observational studies that enrolled patients with functional MR, published in 2020 and 2021. No further restrictions were implemented. Independent reviewers performed study selection, data extraction, risk-of-bias and quality-of-evidence assessments. Variables of interest were related to patient demographics, medications, echocardiogram parameters, and outcomes. Patient variables from observational studies were compared with those reported in randomized trials, using a random-effects model for each variable. Mean difference (MD) and odds ratio (OR), with 95% confidence intervals (95% CI), were used to compare continuous and categorical data, respectively. Variables that were not reported in both COAPT and MITRA-FR trials were not presented. R software was used for non-comparative pooling of variables, and RevMan software was used for comparative meta-analysis.

Results

Thirty-two studies, enrolling 9497 patients, were included. Patients were found to be older in real-life than in landmark trials ([MD −2.73; 95% CI: −4.06, −1.40] for COAPT; [MD −4.33; 95% CI: −5.94, −2.72] for MITRA-FR), while more males were recruited in MITRA-FR trial (OR 1.71; 95% CI: 1.15–2.52). Moreover, patients in MITRA-FR trial were less likely to have atrial fibrillation or renal insufficiency. Patients from real-life were more likely to be more symptomatic (i.e., New York Heart Association (NYHA) class III/IV) and less likely to have implanted cardiac devices than those in randomized trials. MITRA-FR trial patients had better compliance with guideline-directed therapies for heart failure with reduced ejection fraction. Ejection fraction ranged from 31.3% to 33.9% between three study arms. More patients in randomized trials presented with moderate-to-severe MR (grade 3+), whereas severe MR (grade 4+) was more common among patients from real-life. Procedure success, defined as MR grade ≤2+, was more frequent in randomized trials, with better symptoms' relief in COAPT trial (NYHA class I/II). There was no difference in number of devices implanted between real-life and landmark trials data. [Tables 1 and 2]

Conclusion

Real-life data on TMVR in functional MR, as presented by low-quality and heterogenous observational studies, showed substantial differences from the results of the main randomized trials.

Funding Acknowledgement

Type of funding sources: None.

Consumer knowledge and awareness of the toxicity and handling of household products at a tertiary care center in Beirut, Lebanon

Household products intoxication is a common and preventable problem. Household product hazard awareness is lacking among consumers in Lebanon, posing a public health hazard. A cross-sectional observational study was conducted at the American University of Beirut Medical Center by administering surveys to 176 adult participants. The surveys focused on demographics, awareness of product toxicity, practices used to avoid intoxication, and sources of information. Each participant was given a score for behavior and awareness. Informative brochures were handed to increase awareness among consumers. We surveyed 176 patients, of whom (84.7%) were females with a mean age of 42.2 ± 13.5 years. Most were married (77.3%), had a college education (76.7%), were employed (62.5%), and were in charge of household cleaning (76.7%). Toilet cleaners were the substances most perceived to be toxic (94.0%). Most people (86.4%) had low to medium scores on behavior, while most (77.3%) had high scores on awareness. Male gender and using product labels as sources of information were associated with higher behavior scores, while referring to a friend or a relative as a source of information on product intoxication was associated with a lower behavior score. Greater awareness scores were strongly associated with being married, having a higher monthly income, and referring to warning signs presented on the labels as a source of knowledge. Unsafe handling and storage of household products are common among consumers in our population. Therefore, it may be necessary to launch education campaigns to improve consumer handling of household products.

Intracoronary pharmacological therapy versus aspiration thrombectomy in patients presenting with ST-segment elevation myocardial infarction (IPAT-STEMI): a systematic review and meta-analysis

Background

Large thrombus load remains a challenge in the interventional cardiology practice. It precludes direct stent implementation and aggravates coronary obstruction leading to impaired myocardial perfusion, worsened cardiac function, and adverse clinical outcomes. Thus, various strategies have been advocated such as aspiration thrombectomy (AT), and/or localized or intracoronary (IC) treatment with thrombolytic agents and/or glycoprotein IIb/IIIa inhibitors (GPI).

Purpose

To evaluate the effectiveness of IC-administered pharmacological agents alone or combined with AT compared with AT alone as an adjunct to percutaneous coronary intervention (PCI) in STEMI patients with large thrombus burden.

Methods

The method was conducted according to the Cochrane Handbook for Systematic Reviews and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. A systematic search strategy using MEDLINE, EMBASE, CENTRALE, Scopus, ProQuest Public Health, Web of Science databases was performed on February 22, 2020 and updated on February 13, 2021. Eligible trials were randomized controlled trials (RCT) comparing IC-administered thrombolytic agents and/or GPI with or without AT to AT alone in patients presenting with STEMI who underwent PCI. The primary outcomes included coronary reperfusion indices e.g., thrombolysis in myocardial infarction (TIMI) flow grade 3 (G3), TIMI myocardial perfusion grade (TMPG) 3, Myocardial blush grade (MBG) 2/3, ST-segment resolution (STR). Others included clinical outcomes e.g., major adverse cardiovascular events (MACE).

Results

Twelve RCT enrolled 1,466 patients were included in the final analysis. The trials were categorized into 3 groups: (1) Thrombolytics [4 RCT], (2) GPI [3 RCT], and (3) GPI+AT [7 RCT]. Groups 2 and 3 included two mutual studies with multiple arms. In comparison with AT alone, thrombolytic therapy, as presented in four RCT, significantly improved TIMI flow G3 (OR = 3.71, 95% CI: 1.85–7.45; P overall effect = 0.0002; heterogeneity = 0%), complete STR (OR = 3.64, 95% CI: 1.60–8.26; P overall effect = 0.002; heterogeneity = 34%) and MACE (OR = 0.47, 95% CI: 0.22–0.99; P overall effect = 0.05; heterogeneity = 46%), but not TMPG 3. Pooling the data of the two studies with similar intervention i.e., thrombolytics + AT further refined the results with statistical improvement of TMPG 3 as well (OR = 5.44, 95% CI: 2.61- 11.34; P overall effect <0.ehab724.211201; heterogeneity = 0%) (Fig. 1). Pooled results for GPI and GPI+AT groups did not show statistical improvement in TIMI flow G3, MBG 2/3, nor complete STR (Fig. 2).

Conclusion

The findings of this meta-analysis showed that IC-administered thrombolytic agents improved myocardial reperfusion and MACE compared with AT alone in STEMI patients undergoing PCI.

Funding Acknowledgement

Type of funding sources: None.

Two-point compression ultrasonography: Enough to rule out lower extremity deep venous thrombosis?

BACKGROUND

Deep venous thrombosis (DVT) is a major cause of morbidity and is a common presenting complaint to the emergency department (ED). Point-of-care two-point compression ultrasonography has evolved as a quick and effective way of diagnosing DVT. The purpose of this study is to validate the prevalence and distribution of venous thrombi isolated to proximal lower extremity veins, other than common femoral and popliteal veins in patients with DVT.

METHODS

This is a single-center retrospective study that looked at patients presenting to the ED of a tertiary care hospital between January 2014 and August 2018. The clinical presentation and laboratory and imaging results were obtained using the hospital's electronic medical record.

RESULTS

A total of 2,507 patients underwent a lower extremity duplex ultrasound during the study period. Among them, 379 (15%) were included in the study. The percentages of isolated thrombi to the femoral vein and deep femoral vein were 7.92% and 0.53%, respectively. When the patients were stratified into the two groups of isolated DVT and two-point compression DVT, there were no statistically significant differences in the laboratory results between both groups. However, immobilized patients and patients with recent surgeries were more likely to have an isolated DVT.

CONCLUSIONS

Thrombi isolated to proximal lower extremity veins other than the common femoral and popliteal veins make up 8.45% of DVTs. Given this significant number of missed DVTs, the authors recommend the addition of the femoral and deep femoral veins to the two-point compression exam.

Mobile device use among emergency department healthcare professionals: prevalence, utilization and attitudes

Mobile devices are increasingly permeating healthcare and are being regularly used by healthcare providers. We examined the prevalence and frequency of mobile device use, and perceptions around clinical and personal usage, among healthcare providers (attending physicians, residents, and nurses) in the Emergency Department (ED) of a large academic medical center in Lebanon. Half of the target population (N = 236) completed the cross-sectional electronic questionnaire. Mobile device usage for personal matters was uniform across all providers, with the highest usage reported by medical students (81.3%) and lowest by attendings (75.0%). Medical formulary/drug referencing applications were the most common application used by providers followed by disease diagnosis/management applications, 84.4% and 69.5% respectively. Most respondents agreed that mobile devices enabled better-coordinated care among providers and were beneficial to patient care. Most respondents also agreed that mobile device use assisted in quickly resolving personal issues and reduced their feeling of stress, yet the majority did not feel that personal usage improved performance at work. Study findings revealed that although healthcare providers value mobile devices' positive impact on coordination of care, the reverse spillover effect of personal issues into the workplace enabled by mobile devices might have some negative impact on performance of staff at work.

Role of urine studies in asymptomatic febrile neutropenic patients presenting to the emergency department

BACKGROUND

The role of urine studies in the detection of urinary tract infection (UTI) in febrile neutropenic patients with urinary symptoms (having a urinary catheter or having a positive urine analysis) is inarguable. However, the evidence is scarce regarding the indication for urine studies in asymptomatic (i.e., without urinary symptoms) patients with febrile neutropenia (FN) presenting to the emergency department (ED). The aim of this study is to evaluate the need for obtaining urine studies in asymptomatic febrile neutropenic patients.

METHODS

This was a retrospective cohort study conducted on adult cancer patients who presented to the ED with FN and had no urinary symptoms. We included all ED presentations of eligible patients between January 2013 and September 2018. Student's t-test and Wilcoxon rank-sum test were used for continuous data, while Chi-square and Fisher's exact tests were used for categorical data. Participants were divided into two groups based on their urine culture (UC) results: negative and positive UCs. Two cut-offs were used for positive UC results: ≥10⁵ cfu/mL and ≥10⁴ cfu/mL.

RESULTS

We included 284 patients in our study. The age of our patient population was 48.5±18.5 years. More than two-thirds (68.7%) of patients had severe neutropenia, while only 3.9% and 9.9% of the patients had positive UCs at ≥10⁵ cfu/mL and ≥10⁴ cfu/mL, respectively. UCs were expectedly positive in most patients with urinalysis (UA) abnormalities. However, 27.3% and 32.1% of patients with positive UCs at ≥10⁵ cfu/mL and ≥10⁴ cfu/mL respectively had a normal UA.

CONCLUSIONS

In our study, the incidence of UTI in adult febrile neutropenic cancer patients who present to the ED without urinary symptoms is low. Consequently, routine urine testing may not be warranted in this population, as it adds unnecessary financial burdens on the patients and delays timely management.

The utility of chest X-ray vs. computed tomography in febrile neutropenia patients presenting to the emergency department

Introduction: Pulmonary infections are not uncommon in patients with febrile neutropenia. Physicians have agreed to perform a chest X-ray (CXR) for all febrile neutropenic patients presenting with respiratory signs/symptoms. Nevertheless, they were divided into two groups when it came to asymptomatic febrile neutropenic patients (i.e. without respiratory signs/symptoms). A superior alternative to CXR is Computed Tomography (CT). CT, in comparison to CXR, was shown to have better sensitivity in detecting pulmonary foci. The aim of our study is to compare the diagnostic performance of CT and CXR in febrile neutropenic patients presenting to the emergency department, regardless of their clinical presentation. We are also interested in the predictors of pneumonia on chest imaging. Methodology: This is a retrospective cohort study conducted on febrile neutropenic adult cancer patients presenting to the emergency department of the American University of Beirut Medical Center. Results: 11.4% of 263 patients had pneumonia although 27.7% had respiratory signs/symptoms. 17.1% of those who were symptomatic and did a CXR were found to have pneumonia. 41.7% of those who were symptomatic and did a CT were found to have pneumonia. 30% had negative findings on CXR but pneumonia on CT. Conclusion: Patients with positive findings of pneumonia on chest imaging mainly had solid tumors, profound neutropenia, a higher CCI and a longer LOS. The presence of respiratory signs is the main predictor of positive pneumonia on chest imaging. CT is superior to CXR in detecting pulmonary foci in the population studied.

Toxicological exposures reported to a telephonic consultation service at a tertiary care hospital in Lebanon

Introduction: This study aims to describe the epidemiology of toxicological exposures reported to a telephonic medical toxicology service at a tertiary care center in Lebanon during a 46-months period.Methods: This study is a secondary analysis of a database for a telephonic medical toxicology service at a tertiary care center in Lebanon. Clinical information from all pediatric and adult patients, presenting with intentional or unintentional toxicological exposure, was entered into the database by the medical toxicology team.Results: Four hundred and seventy-seven exposures were recorded from 1 March 2015 to 31 December 2018. Female patients were involved in 60.2% of cases. Children less than 5 years old constituted 23.5% of cases and adults aged 20-49 constituted 48.6%. Up to 51.6% of cases were intentional, with 37.7% resulting from suicidal attempts. The majority of patients displayed no effects (33.1%) or minor effects (39.2%). Almost half of patients were treated and discharged from the Emergency Department (ED) without further hospitalization, and another 18.9% of patients left the ED against medical advice. The most common pharmaceutical agents involved were sedative/hypnotics/antipsychotics (14.7%), analgesics (12.6%) and antidepressants (11.3%). The most common non-pharmaceutical agents involved were household cleaning substances (8.0%), pesticides (5.2%) and bites and envenomations (3.8%).Conclusions: The results of this study suggest that sedative/hypnotics/antipsychotics, analgesics, antidepressants and household cleaning substances are the most common agents involved. Adult women and children ≤5 years old constitute a large portion of patients with toxicological exposures. Prevention strategies and policies should be implemented to mitigate these hazards.

Characteristics and determinants of high-risk unscheduled return visits to the emergency department

Background

High-risk unscheduled return visits (HRURVs), defined as return visits within 72 hours that require admission or die in the emergency department (ED) on representation, are a key quality metric in the ED. The objective of this study was to determine the incidence and describe the characteristics and predictors of HRURVs to the ED.

Methods

Case–control study, conducted between 1 November 2014 and 31 October 2015. Cases included all HRURVs over the age of 18 that presented to the ED. Controls were selected from patients who were discharged from the ED during the study period and did not return in the next 72 hours. Controls were matched to cases based on gender, age (±5 years) and date of presentation.

Results

Out of 38 886 ED visits during the study period, 271 are HRURVs, giving an incidence of HRURV of 0.70% (95% CI 0.62% to 0.78%). Our final analysis includes 270 HRURV cases and 270 controls, with an in-ED mortality rate of 0.7%, intensive care unit admission of 11.1% and need for surgical intervention of 22.2%. After adjusting for other factors, HRURV cases are more likely to be discharged with a diagnosis related to digestive system or infectious disease (OR 1.64, 95% CI 1.02 to 2.65 and OR 2.81, 95% CI 1.05 to 7.51, respectively). Furthermore, presentation to the ED during off-hours is a significant predictor of HRURV (OR 1.64, 95% CI 1.11 to 2.43) as is the presence of a handover during the patient visit (OR 1.68, 95% CI 1.02 to 2.75).

Conclusion

HRURV is an important key quality outcome metric that reflects a subgroup of ED patients with specific characteristics and predictors. Efforts to reduce this HRURV rate should focus on interventions targeting patients discharged with digestive system, kidney and urinary tract and infectious diseases diagnosis as well as exploring the role of handover tools in reducing HRURVs.

Episiotomy practice in the Middle East: A Lebanese teaching tertiary care centre experience

PROBLEM

There is lack of data on the rate of episiotomy in Lebanon and the study's hospital.

BACKGROUND

Only a few studies have addressed episiotomy practice in Lebanon and the Middle East and they show varying rates.

AIM

To identify the rate, and change in rate, of episiotomy practice over the years at a teaching hospital in Lebanon and to assess whether maternal age, parity, fetal weight, woman's hospital admission class, and physician's gender were associated with episiotomy. We also tested the association between episiotomy and postpartum hemorrhage and/or high degree perineal tears.

METHODS

A retrospective observational study was conducted on 1756 records for women having a normal vaginal birth at a single centre from January 2009 to January 2014.

FINDINGS

The rate of episiotomy at the hospital was very high, with 97.4% of women receiving an episiotomy in 2009. A major decrease in the rate was identified with a decline from 97.4% in 2009 to 73.3% in January 2014. Episiotomy was found to be associated with parity, maternal age, and with high degree perineal tears.

DISCUSSION

The episiotomy rate at this centre remains higher than the 10% rate recommended by the World Health Organization, although there has been a significant reduction after a call for restrictive rather than liberal use.

CONCLUSION

Raising awareness among providers appeared to play a significant role in reducing this rate, although more efforts remain warranted. Other strategies - such as raising awareness of women about potential risks of episiotomy - are also worth exploring.

A new syndrome of congenital hypoparathyroidism, severe growth failure, and dysmorphic features

Twelve infants (six boys, six girls) with severe hypocalcaemic tetany or convulsions were seen over a three year period. Nine patients were symptomatic in the newborn period. Their hypocalcaemia was associated with hyperphosphataemia and very low concentrations of immunoreactive parathyroid hormone. None of the babies suffered from congenital cardiac disease. Cell mediated immunity, measured in five patients, was normal. There were no chromosomal abnormalities but all patients shared several dysmorphic features including deep set eyes, microcephaly, thin lips, beaked nose tip, external ear anomalies, micrognathia, and depressed nasal bridge. Mental retardation of varying degree was found in all patients. All had severe intrauterine and postnatal growth retardation. Four patients have died. The remaining eight patients are on treatments with vitamin D and calcium supplements with no change in their growth pattern. We believe that this association of congenital hypoparathyroidism with severe growth failure and dysmorphism represents a new syndrome.

Repair of large midline abdominal-wall hernias by a running strip of abdominal skin

Our experience with a full-thickness running strip of abdominal skin for the treatment of large midline abdominal hernias has been very positive. The mechanical properties of the skin strip allow one to reestablish a normal anatomy by bringing the rectus muscle in contact. Clinical and histologic studies have shown that the full-thickness skin rapidly loses its epidermal components and appears to transform itself into a dense connective tissue very similar to normal aponeurosis.