American University Of Beirut Medical Center Research Articles

Short-Term Clinical Outcomes of Transcatheter Aortic Valve Replacement in a Developing Country.

Transcatheter aortic valve replacement (TAVR) is an effective alternative to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis in all surgical risk groups. Reports of clinical outcomes post-TAVR in developing countries are scarce. We aimed to address the clinical outcomes and safety profile of TAVR in a developing country. We conducted a single-center, retrospective study on patients undergoing TAVR at the American University of Beirut Medical Center (AUBMC) from January 2016 to April 2023. We included a total of 399 patients. Our primary endpoint was to assess the rate of TAVR in-hospital and 30-day mortality, neurologic events, and new permanent pacemaker implantation (PPI)in patients, stratified by the Society ofThoracic Surgeons (STS) risk of mortality score. Survival rates were 98.7% (394) at discharge vs. 97.5% (389) at 30 days post-procedure. The technical success rate was 95% (379) at the end of the procedure. Device success and early safety rates were 93.5% (373) and 83% (331), respectively at 30 days post-procedure. The all-cause mortality rate increased from 1.3% (5) at discharge to 2.5% (10) at 30-day intervals. The rate of ischemic stroke was 1.3% (five) at discharge and increased to 2% (eight) at 30 days post-procedure. PPI was needed in 5.8% (23) of patients at discharge with an increase to 7% (28) at one-month interval. Overall, the rates of TAVR outcomes among the three risk groups were comparable including neurologic events, valve-related complications, bleeding problems, vascular and access-related complications, and myocardial infarction. This study at AUBMC highlights the successful implementation of the TAVR program in a developing country, showcasing its efficacy and safety within 30 days post-operation, despite challenges such as financial constraints and limited access to specialized training. Larger cohorts and longer follow-up periods are needed to accurately represent clinical outcomes in developing countries.

Efficacy and Safety of Intravenous Vernakalant in Rapid Cardioversion of Recent Onset Atrial Fibrillation: A Retrospective Single-Centre Study.

We use vernakalant, an intravenous anti-arrhythmic, to cardiovert paroxysmal atrial fibrillation (AF) into sinus rhythm. It is a relatively atrium-selective, early-activating potassium and frequency-dependent sodium channel blocker with a half-life of 2 to 3 hours. Due to concerns regarding its safety profile, it is not Food and Drug Administration (FDA)-approved. This study aims to assess the efficacy of intravenous vernakalant in cardioversion of paroxysmal AF and the safety of its use. Patients with paroxysmal AF who presented to the American University of Beirut Medical Center (AUBMC) between 2015 and 2020 and received vernakalant for cardioversion were included. Patients did not receive vernakalant if they had any of the following: QTc > 440 ms, heart rate < 50 bpm, acute coronary syndrome within the last 30 days, second- and third-degree atrioventricular (AV) block in the absence of a pacemaker, severe aortic stenosis (AS), use of intravenous antiarrhythmics (class I and class III) within four hours of vernakalant infusion, systolic blood pressure <100 mmHg, and heart failure (New York Heart Association (NYHA) III or NYHA IV class). The primary endpoint is conversion to sinus rhythm for at least one minute within 90 minutes of the start of the vernakalant infusion. The secondary endpoint included the presence of these side effects: bradycardia, QTc prolongation, AV block, ventricular arrhythmias, hypotension, taste alteration/dysgeusia, sneezing, nausea, vomiting, paresthesia, cardiogenic shock, or death. The study included 23 patients with paroxysmal AF (15 men, mean age 54 ± 14 years). Fourteen patients (61%) cardioverted to sinus rhythm within 90 minutes of the start of the Vernakalant infusion. Seven patients (30%) reverted to sinus rhythm within 15 minutes after the first infusion. After treatment with vernakalant, four patients (17%) developed sinus bradycardia, and four patients (17%) developed first-degree AV block. No patient had a QTc greater than 460 ms. None of the patients experienced sinus pauses, high-grade AV block, ventricular arrhythmias, hypotension, dysgeusia, sneezing, nausea, vomiting, paresthesia, cardiogenic shock, or death. Vernakalant had 61% efficacy in the rapid cardioversion of paroxysmal AF to sinus rhythm, was well tolerated, and had a low rate of adverse events in our study population.

Accelerated corneal crosslinking with 20'-soaking hydroxypropyl methyl cellulose/riboflavin vs conventional crosslinking with 30'-soaking dextran/riboflavin.

To evaluate and compare functional and structural outcomes of accelerated corneal crosslinking (A-CXL) using riboflavin with hydroxypropyl methyl cellulose (HPMC) vs conventional corneal crosslinking (C-CXL) using riboflavin with dextran. American University of Beirut Medical Center, Beirut, Lebanon. Retrospective analysis. Retrospective analysis of 83 eyes of 73 patients with mild to moderate keratoconus. First group (n = 44 eyes) underwent C-CXL using a 30-minute riboflavin/dextran soaking between June 2014 and March 2016. Second group (n = 39 eyes) underwent A-CXL using a 20-minute riboflavin/HPMC soaking between April 2016 and December 2017. Patients were evaluated preoperatively and at 1, 3, and 12 months postoperatively. Main outcome measures were simulated keratometry (simK), maximum axial keratometry (Kmax), demarcation line depth, and haze intensity measured using optical coherence tomography-based image analysis software. Demarcation line (DL) was 298.30 ± 64.60 μm and 335.61 ± 99.76 μm for C-CXL and A-CXL groups, respectively ( P = .04). Haze profile was similar for both groups. The mean simK values were reduced from 46.93 ± 3.50 and 46.44 ± 2.93 preoperatively to 46.18 ± 3.65 and 45.54 ± 2.78 at 12 months postoperatively, for C-CXL and A-CXL, respectively ( P = .003 for both groups). The mean Kmax decreased from 52.46 ± 4.82 and 51.50 ± 3.87 preoperatively to 51.30 ± 4.42 and 50.30 ± 3.52 postoperatively, for the C-CXL and A-CXL, respectively ( P < .001 for both groups). There was no difference in the simK and Kmax changes between the C-CXL and A-CXL groups ( P = .814 and P = .913), visual acuity, and refraction between the 2 groups ( P > .05). A-CXL with a 20-minute riboflavin/HPMC soaking produced deeper DL and similar corneal haze, topographic, refractive, and visual results to C-CXL with a 30-minute riboflavin/dextran soaking.

Genomic profiling of bladder cancer in waterpipe and cigarette smokers: Implications for carcinogenicity and genetic landscape.

657 Background: While cigarette smoking is a well-established risk factor for bladder cancer (BC), limited research has explored the contribution of waterpipe smoking (WPS) to BC. WPS is gaining popularity among Middle Eastern youth, often perceived as a safer alternative to cigarettes. Alarmingly, Lebanese males had an age-standardized incidence rate of 54.0 per 100,000 in 2019, the highest in the Arab World and five times the global average, prompting a critical investigation into potential risk factors. Mounting evidence suggests that WPS exposes users to toxicants and carcinogens that can induce chromosomal damage contributing to cancer. This study aims to assess the genomic and mutational profiles of BC in waterpipe smokers compared to cigarette smokers. Methods: This cross-sectional study enrolled adults with urothelial carcinoma (UC) who exclusively smoked waterpipe at the American University of Beirut Medical Center (AUBMC) between April 2017 and September 2019. Next-generation sequencing by MSK-IMPACT characterized mutational profiles, tumor mutation burden, and microsatellite instability (MSI) status in tumor-normal pairs. For comparison, a cohort from Memorial Sloan Kettering Cancer Center (MSKCC), comprising previously profiled BC tumors from cigarette smokers, was used. Results: A total of 14 exclusively WPS-BC patients were enrolled, with 12 males (85.7%) and a median age at diagnosis of 62.9 years (range: 30.7 to 78.9). Among these patients, 9 (64.3%) had non-muscle invasive BC, with 8 (57.2%) classified as high-grade UC. MSK-IMPACT sequencing successfully analyzed 13 WPS samples, revealing genomic patterns similar to the cigarette smoking cohort. Common genetic alterations in the WPS cohort included mutations in TERT promoter (62%), TP53 and FGFR3 (46% each), and PIK3CA (38%). Mutations in chromatin modifiers were less prevalent, with the highest frequencies observed in KDM6A (31%) and KMT2C (15%). The tumor mutation burden was higher in the WPS group (22 per MB) compared to the cigarette smoking cohort (9 per MB), with no definite evidence of MSI. PD-L1 expression was generally low, with only 2 samples exhibiting combined positivity scores (CPS) of 15 and 10, primarily associated with immune cells PD-L1 expression. Only one tumor demonstrated 3% PD-L1 expression on tumor cells, while 7 tumors displayed no expression on either tumor or immune cells (CPS of 0). Conclusions: This study underscores the genomic similarities between BC in waterpipe and cigarette smokers. The preliminary findings, limited by sample size, highlight the need for further investigations to elucidate the potential role of WPS in BC development. Future efforts will focus on cohort expansion to validate initial observations, raising awareness of health risks associated with WPS, and emphasizing the importance of continued research to inform preventive strategies.

Esophageal cancer: a twenty-four-year experience at a tertiary care center with an evaluation of the prognostic significance of the neutrophil-lymphocyte ratio

BackgroundA high neutrophil-lymphocyte ratio (NLR) may be associated with worse survival in esophageal cancer (EC). Our aims were to describe the demographic and clinical data of EC in a tertiary referral center in Lebanon and to determine the prognostic value of NLR.MethodsA retrospective cohort study based on chart review of patients diagnosed with EC was conducted at the American University of Beirut Medical Center (AUBMC). The demographic characteristics, clinical presentation and outcomes were described and compared between squamous cell carcinomas (ESCC) and adenocarcinomas (EAC). Data about esophageal cancer incidence were obtained from the National Cancer Registry, the Ministry of Public Health and GLOBOCAN 2020. Cox regression analysis was performed to determine whether the NLR is an independent predictor of survival, using variables based on clinical knowledge and previously established data.Results110 patients were diagnosed with EC, which was the least common among other gastrointestinal malignancies. Our follow up rates reached 86.4%. The median survival was 9 months (IQR 3–25.5.) and was comparable between ESCC (median of 7 months, IQR 2–25) and EAC (median of 9 months, IQR 3–26.3), p = 0.803. Advanced stage was associated with a worse prognosis (p = 0.037). The mean NLR(±SD) was 5.20 ± 6.8, with no significant difference between EAC and ESCC (4.5 ± 3.4 vs. 5.9 ± 9.2, p = 0.420) or between early or advanced stages (5.4 ± 8.1 vs. 4.7 ± 6.8, p = 0.732). The area under the curve for the NLR was 0.560 (95% CI: 0.374–0.746, p = 0.488). After adjusting for age, gender, TNM staging and grading, cox regression analysis showed that an increased NLR was a significant predictor of mortality, with an adjusted hazard ratio of 1.095 (p = 0.011).ConclusionEC is quite uncommon in Lebanon despite a high prevalence of smoking and obesity. Advanced stage and high NLR were associated with a negative prognostic value.

Risk Factors for SARS-CoV-2 Among a Cohort of Healthcare Workers in Lebanon.

Healthcare workers (HCWs) faced substantial risk of infection during the COVID-19 outbreak. This study aims to determine the prevalence of anti-SARS-CoV-2 antibodies in a cross-sectional sample of HCWs as well as risk factors associated with exposure to SARS-CoV-2. The study was conducted between March and May 2021 at the American University of Beirut Medical Center (AUBMC), a tertiary hospital located in Lebanon. Socio-demographic and clinical data, as well as data on exposure, PCR results, PPE adherence, and vaccination status, were collected using an online questionnaire. Sera were also collected to determine seropositivity using commercially available enzyme-linked immunoassay (ELISA) targeting the spike (S) and the nucleocapsid proteins (NCP) of SARS-CoV-2. Among 92 recruited HCWs, 72.3% received PPE training, more than 70% were adherent to using appropriate PPEs, and around 80% were vaccinated. Nurses in this study population were at higher risk of exposure compared to medical doctors, technicians, and other HCWs. Among the HCWs who performed a PCR test, 28.6% were infected with SARs-CoV-2 with workplace exposure not associated with COVID-19 infection. All vaccinated HCWs were seropositive for anti-S IgG with high titer (≥384 BAU/mL), with a significantly higher median anti-S IgG titer compared to unvaccinated HCWs with previous infection (384 vs. 140.1 BAU/mL; p = .0043). Our study highlights the importance of implementing strict infection control policies among HCWs and deploying an effective COVID-19 vaccination strategy. More studies are needed in Lebanon to assess risk factors of SARS-CoV-2 exposure in the workplace.

2584. Predictors of Clinically Significant Infection in Patients with Mycobacterium simiae Isolated from Respiratory Samples: a Retrospective Study from a Tertiary Care Center in Lebanon

Abstract Background Mycobacterium simiae is a rare slow-growing, non-tuberculous mycobacterium (NTM). It is predominant in Middle Eastern countries like Israel, Iran and Lebanon and is the most isolated NTM spp. at our institution (40%). Little is known about its reservoirs, pathogenesis, risk factors and indications for treatment. Methods We retrospectively studied patients with respiratory cultures showing M. simiae at the American University of Beirut Medical Center (AUBMC) over 19 years. We used the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) criteria to define NTM lung disease. Samples were cultured at AUBMC using Lowenstein-Jensen media and the BacT/ALERT system. NTM isolates were referred for speciation and susceptibility testing at Mayo Clinic, MN, USA. Results We identified 72 isolates from 66 patients. Most were obtained from sputum samples (57.6%), the rest from bronchoalveolar lavages (BAL). Acid-fast bacilli smear was positive in 27% of samples with no difference between sputum and BAL. The median age of patients was 64 years and 51.5% were females. Bronchiectasis (34.5%), chronic obstructive pulmonary disease (27.3%) and immunosuppression (33.3%) were common (Table 1). As per the ATS/IDSA criteria, 67.9% of patients had NTM lung disease. The most common symptoms were cough (83.3%) and sputum production (74.5%). All patients except 2 had abnormal findings on CT imaging like nodules (58.5%), tree in bud aspect (45.3%) and bronchiectasis (24.5%). Among those, 55.6% had abnormal CT findings preceding the M. simiae isolation. Bronchiectasis was more common in those who satisfied the ATS/IDSA criteria versus those who did not (38.9% vs 20.0%). Otherwise, we found no significant differences between both groups (Table 2). Treatment was given to 88.9% of patients who satisfied the NTM lung disease and 42.1% of those who did not (p&amp;lt; 0.001) with a median duration of 12 months. Of those with available follow-up, relapse was reported in 24% of cases. Characteristics of patients with M. simiae isolated from respiratory samples. BMI, body mass index, COPD, chronic obstructive pulmonary disease, AFB, acid-fast bacilli. *Median(Interquartile range) **Composite variable including hematologic malignancy, solid organ malignancy, hematopoietic transplantation, solid organ transplant, chronic steroids treatment, and active chemotherapy. Clinical and radiological differences between patients with M. simiae lung disease and those colonized according to the ATS/IDSA criteria. BMI, body mass index, COPD, chronic obstructive pulmonary disease. *Median (Interquartile range) Conclusion M. simiae is a significant cause of NTM lung disease at our institution with a high rate of relapse. Further research is required to understand its geographic restriction, predisposing factors, and identify patients at risk for clinically significant infection. Disclosures Souha S Kanj, MD, Gilead: Advisor/Consultant|Menarini: Advisor/Consultant|MSD: Advisor/Consultant|Pfizer: Advisor/Consultant

1263. The Experience of an Antimicrobial Stewardship Program at a Tertiary Referral Hospital in a Low/Middle Income Country

Abstract Background Antimicrobial Stewardship Programs (ASP) play a crucial role in optimizing antimicrobial utilization and limiting the use of broad-spectrum antibiotics, to reduce antimicrobial resistance. During the COVID-19 pandemic, there was a noticeable increase in antimicrobial consumption globally. The ASP at the American University of Beirut Medical Center (AUBMC) began formal operations in January 2019. In this study, our aim is to evaluate the activities of the ASP -since implementation and during the pandemic- at our institution, a tertiary referral hospital in Beirut. Methods The ASP team performed handshake stewardship rounds and daily reviews of antimicrobial use. It provided educational activities in a multi-disciplinary approach in addition to implementing a carbapenem sparing strategy and ongoing monitoring of antibiotic consumption. This study is a retrospective review of those activities. We compiled the ASP recommendations from January 2019 until December 2021. Data collected included the number of ASP recommendations and their sub-categories in addition to acceptance rates. Results We recorded a total of 9922 recommendations during this three-year period. Recommendations aiming at reducing antimicrobial consumption were the most common (42%), and included: duration of therapy, de-escalation, and duplicate coverage (Figure 1). Rates of acceptance of these recommendations were 88%, 92% and 95% in 2019, 2020 and 2021 respectively. The number of recommendations increased during the pandemic and coincided with COVID-19 surges in Lebanon (figure 2). There was also an increase in the acceptance rate of recommendations to reduce antibiotic consumption (Figure 3) over this period.Figure 1.Distribution of ASP Interventions per sub-CategoryFigure 2.Number of ASP Recommendations pre- and During COVID-19Figure 3.ASP recommendations to Reduce Antibiotic Consumption and Acceptance Rate Conclusion Despite the challenges imposed by the pandemic and the involvement of the ASP in the COVID-19 response, the team maintained its efforts and involvement to mitigate antibiotic misuse. The results are encouraging and attest to the important role of ASP in driving culture change regarding the judicious use of antimicrobials even during a pandemic. Disclosures Souha S Kanj, MD, Gilead: Advisor/Consultant|Menarini: Advisor/Consultant|MSD: Advisor/Consultant|Pfizer: Advisor/Consultant

Grading reflective essays: the construct validity and reliability of a newly developed Tool- GRE-9

BackgroundThe main objective of this study is to assess the construct validity and reliability of the Grading Reflective Essays-9 (GRE-9).MethodsThis study took place in a major tertiary academic medical center in Beirut, Lebanon. 104 reflective essays written by years 1–3 residents in the department of Family Medicine at the American University of Beirut Medical Center (AUBMC) were graded by 2 trained raters who independently scored the essays using GRE-9. GRE-9 scores were then correlated with scores on communication skills OSCE stations and in-training examinations to investigate, respectively, convergent and divergent validity. One of the 2 raters scored the essays twice one month apart to assess the reliability of the GRE-9 using intra rater reliability and internal consistency.ResultsThere was a weak, non-significant correlation between GRE-9 score and In training examination (ITE) score (r = − .213, p = .395). There was a moderate, non-significant correlation between GRE-9 scores and the Objective structured clinical examination (OSCE) communication station scores (r = − .412 p = .162). The correlation coefficient between trails 1 and 2 was significant (r = .832, p = .000). Intra class correlation coefficient (ICC) analysis demonstrated almost perfect intra-rater agreement (0.819; 95% CI: 0.741–0.875) of the test ratings over time.ConclusionsGRE-9, is a short, concise, easy-to-use reliable grading tool for reflective essays that has demonstrated moderate to substantial intra-rater reliability and evidence of divergent validity. The study found non-significant correlations between reflective writing scores OSCE communication scores demonstrating a lack of relationship between reflective writing and this measure of performance.

Cannabis use and psychosis among patients hospitalized in psychiatric wards in Lebanon: a retrospective chart review

BackgroundTrends in cannabis use suggest a global increase in the past decade. Current evidence associates cannabis use with an increased risk of psychosis. This association has prompted a growing research interest in the association between cannabis use and psychiatric disorders, especially psychotic disorders. This study aims to gain a better understanding of the effect of cannabis on psychosis and its clinical progression.ResultsWe conducted a retrospective chart review of cannabis use in patients hospitalized for a psychosis episode over five years at the American University of Beirut Medical Center (AUBMC). Cannabis users were more likely to be young single males using other substances compared to non-cannabis users. Frequent cannabis use was associated with a higher likelihood of paranoia and legal problems. Other psychotic symptoms did not significantly differ between frequent cannabis users and non-users. The length of hospital stay and the duration of the psychotic episode did not significantly differ between cannabis users and non-users. Family stressors and family history of a psychotic disorder were associated with a higher likelihood of personal history of violence.ConclusionsThis study is the first in Lebanon to reproduce findings supporting the association between cannabis and psychosis previously highlighted in other populations. Further prospective research is needed to better understand the effect of cannabis use on psychosis and to accordingly revise policies on cannabis legalization to reduce the global burden of psychotic disorders.

Bacterial respiratory infections in patients with COVID-19: A retrospective study from a tertiary care center in Lebanon

BackgroundDespite multiple reports of increased incidence of bacterial respiratory tract infections following COVID-19 globally, the microbiology is not yet fully elucidated. In this study, we describe the microbiology of bacterial infections and the prevalence of multidrug resistant organisms (MDROs) in hospitalized COVID-19 patients with community-acquired pneumonia (CAP), and hospital-acquired pneumonia (HAP) which includes both non-ventilated hospital acquired pneumonia (NVHAP) and ventilator-associated pneumonia (VAP). To our knowledge, this is the first study that compares the microbiology of VAP and NVHAP in COVID-19 patients. MethodsThis is a longitudinal retrospective cohort study conducted at the American University of Beirut Medical Center (AUBMC), a tertiary-care centre in Lebanon. Adult patients with confirmed COVID-19 and concurrent bacterial respiratory infections with an identifiable causative organism who were hospitalized between March 2020 and September 2021 were included. Bacterial isolates identified in hospital-acquired pneumonia (HAP) were divided into 3 groups based on the time of acquisition of pneumonia after admission: hospital day 3–14, 15–28 and 29–42. ResultsOut of 1674 patients admitted with COVID-19, 159 (9.5%) developed one or more respiratory infections with an identifiable causative organism. Overall, Gram-negative bacteria were predominant (84%) and Stenotrophomonas maltophilia was the most common pathogen, particularly in HAP. Among 231 obtained isolates, 59 (26%) were MDROs, seen in higher proportion in HAP, especially among patients with prolonged hospital stay (> 4 weeks). Non-fermenter Gram-negative bacilli (NFGNB) (OR = 3.52, p-value<0.001), particularly S. maltophilia (OR = 3.24, p-value = 0.02), were significantly more implicated in VAP compared to NVHAP. ConclusionsNFGNB particularly S. maltophilia were significantly associated with COVID-19 VAP. A high rate of bacterial resistance (25%), especially among Gram-negative bacteria, was found which may compromise patients’ outcomes and has important implications in guiding therapeutic decisions in COVID-19 patients who acquire bacterial respiratory infections.

Efficacy of lung cancer screening at the American University of Beirut Medical Center.

In Lebanon, a dedicated screening program for lung cancer is absent. Screening is largely based on the recommendation of an informed physician or the initiative of a patient. To better understand the situation, it is important to look at the available data on patients currently being screened for lung cancer in this country. Our aim in this study is to review the data and compare it with that in the literature as well as to assess the efficacy of the screening process followed. Our study accessed the electronic medical records of patients at the American University of Beirut Medical Center (AUBMC), a tertiary care center in Lebanon. We collected information on patients who underwent screening low-dose computed tomography (LDCT) scan between June 2019 and June 2021 inclusive. Records of all patients who underwent a non-contrast computed tomography (CT) scan at AUBMC during this period were collected and analyzed. On average, our population had a 52.6 pack-year smoking history. Moreover, 47% of our population had an accurate pack-year reported, while 12% did not have enough information to even estimate their pack-year history. When looking at the accurate and estimated data, 5% of our population did not even meet the ≥20 pack-year smoking history. Eight patients had positive findings on the screening LDCT, which we defined as suspicious findings that require further workup (e.g., PET/CT or biopsy) or other significant incidental findings. A well-organized program for lung cancer screening in Lebanon is absent. Screening largely depends on the initiative of the physician or the patient. We were able to uncover multiple flaws in the screening method used, including poor documentation and follow-up. Although the screening method adopted retained some benefits in terms of detecting early malignancy, it lacked proper organization and was not ideal. A better, systematized screening program is needed to have optimal outcomes.

Mucormycosis: A 14-Year Retrospective Study from a Tertiary Care Center in Lebanon.

Mucormycosis (MCM) is a serious invasive fungal disease (IFD) that is associated with high mortality, particularly in immunocompromised patients. A global surge in MCM cases was reported with the COVID-19 pandemic. We analyzed all recorded cases of MCM at the American University of Beirut Medical Center (AUBMC), a tertiary care center in Lebanon, over 14 years. We aimed to identify the incidence, seasonal variation, clinical characteristics of the patients, and predictors of mortality. We conducted a retrospective chart review between 1 January 2008 and 1 January 2023. All patients with proven or probable MCM were included in the study. Proven or probable MCM was defined by positive histopathology and/or positive cultures. A total of 43 patients were identified as having MCM. Their median age was 53 years, and the majority were males (58.1%). Most of the cases were diagnosed in the autumn season. In total, 67.4% of the patients had hematological malignancies (HMs), and 34.9% had uncontrolled diabetes mellitus (DM). The most common site of involvement was rhino-orbital-cerebral MCM (ROCM) (74%). The annual cases of MCM per 100,000 patient days increased markedly during the years of the COVID-19 pandemic (from 0 to 4.4 cases/100,000 patient days to 7.5 cases/100,000 during 2020 and 2021). Liposomal amphotericin (Ampho) B was used as a first-line agent in most of the patients (86%). The median duration of total in-hospital antifungal therapy was 21 days and 51.2% of the patients received step-down therapy with azoles. Surgical debridement and isolated ROCM were significantly associated with survival (p-value: 0.02 and <0.001, respectively). All-cause mortality was 46.7%, with chronic renal disease being significantly associated with mortality (p-value < 0.05). The incidence of MCM has been increasing at our institution, particularly since the COVID-19 pandemic. Early diagnosis, treatment, and surgical debridement improve patient outcomes and overall survival.

Beirut Port Blast 2020: New Lessons Learned in Mass Casualty Incident Management in the Emergency Department

BackgroundOn August 4, 2020, Lebanon suffered its largest mass casualty incident (MCI) to date: the Beirut Port blast. Hospital emergency response to MCIs is particularly challenging in low- and middle-income countries, where emergency medical services are not well developed and where hospitals have to rapidly scale up capacity to receive large influxes of casualties. This article describes the American University of Beirut Medical Center (AUBMC) response to the Beirut Port blast and outlines the lessons learned. DiscussionThe Beirut Port blast reinforced the importance of proper preparedness and flexibility in managing an MCI. Effective elements of AUBMC's MCI plan included geographic-based activation criteria, along with use of Wi-Fi messaging systems for timely notification of disaster teams. Crowd control through planned facility closures allowed medical teams to focus on patient care. Pre-identified surge areas with prepared disaster cart deployment allowed the teams to scale up quickly. Several challenges were identified related to electronic medical records (EMRs), including patient registration, staff training on EMR disaster modules, and cumbersome EMR admission process workflows. Finally, this experience highlights the importance of psychological debriefs after MCIs. ConclusionsHospital MCI preparedness plans can integrate several strategies that are effective in quickly scaling up capacity to respond to large MCIs. These are especially necessary in countries that lack coordinated prehospital systems.

Abstract 5792: The novel therapeutic diiminoquinone exhibits anticancer effects on human prostate cancer cells in 2D and 3D in vitro models

Abstract Aim: To investigate the anticancer potential of the novel quinone DIQ on prostate cancer (PCa) cells in two-dimensional (2D) and three-dimensional (3D) in vitro. Methods: The anti-proliferative effect of DIQ on PC3 and DU145 PCa cell lines was determined in vitro by using 3-(4,5 dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and trypan blue exclusion assays. In addition, the potency of DIQ was tested on the formation and size of PCa cell-derived prostatospheres and organoids grown in a specialized 3D-culture system. Also, 3D organoids were established from fresh tissue samples representing different stages of PCa obtained from consented patients who underwent radical prostatectomy at the American University of Beirut Medical Center (AUBMC) according to appropriate Institutional Review Board (IRB) approval guidelines. This model was used to assess DIQ individualized tumor response on organoids growth and the effect was evaluated by quantifying the number of organoids formed (OFC) and calculating the average size (diameters). Results: Our results showed that DIQ significantly attenuated cell proliferation and viability in PC3 and DU145 PCa cell lines. DIQ also reduced the formation ability and size of PC3 and DU145 prostatospheres and organoids at sub-toxic doses of 1 µM. Potently, DIQ displayed a significant decrease in both the count and the size of the different patient-derived organoids as compared to their respective control. Conclusion: This study provides promising clues for the use of the novel anticancer therapeutic DIQ in targeting CSCs, findings that may have promising therapeutic implications for PCa patients. Citation Format: Amani Yehya, Alissar Monzer, Kevork Wakimian, Fatima Ghamlouche, Nour Saheb, Ayman Tawil, Hala Gali-Muhtasib, Deborah Mukherji, Albert El-Hajj, Wassim G. Abou-Kheir. The novel therapeutic diiminoquinone exhibits anticancer effects on human prostate cancer cells in 2D and 3D in vitro models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5792.

Human leukocyte antigens and adult acute myeloid leukemia: A first report from Lebanon

IntroductionAcute Myeloid Leukemia (AML) represents the most common type of acute leukemia in adults and the second most common form of leukemia in general. AML has been associated with HLA alleles and these correlations have been widely investigated worldwide. ObjectiveThe aim of this study is to analyze the antigen frequency of HLA Class I (HLA-A, HLAB, and HLAC) and Class II (HLA-DRB1 and HLA-DQB1) among AML Lebanese adult patients. MethodsThis is a retrospective study reviewing all the HLA results of 121 adult patients admitted to the American University of Beirut Medical Center (AUBMC) from January 2017 to May 2022. Comparison of HLA frequency in AML patients to frequency in general Lebanese population published in previous studies was done. ResultsIn HLA class I, an increased frequency of HLA-A*03 (OR, 1.61; 95% CI, 1.10 to 2.37; P = 0.02), HLA-A*25 (OR, 6.69; 95% CI, 1.78 to 25.07; P = 0.01), HLA-A*74 (OR, 8.33; 95% CI, 1.67 to 41.51; P = 0.02) was found in the AML group, whereas decreased frequency of HLA-B*15 (OR, 0.22; 95% CI, 0.05 to 0.93; P = 0.03) was noted. In HLA class II, DRB1*03 (OR, 0.27; 95% CI, 0.14 to 0.50; P < 0.001) was higher among the control group and DRB1*12 (OR, 15.71; 95% CI, 1.88 to 131.20; P = 0.01) among the AML group. ConclusionFindings revealed that three class I HLA antigens are predisposing to AML (HLA-A*03; HLA-A*25; HLA-A*74) and one class I HLA antigen is protective (HLA-B*15). Regarding class II HLA antigens, DRB1*03 was found to be protective whereas DRB1*12 was found to be predisposing to AML.

Abstract P6-02-17: A Real-World Study of BRCA1 and BRCA2 Germline Mutations among High Hereditary Risk Subjects and Patients with Breast and Ovarian Cancer in Lebanon

Abstract Background: The prevalence of pathogenic BRCA mutations in high hereditary risk breast cancer patients (pts) in ethnic Lebanese Arab women was 5.6% in a study published in 2015 (El Saghir, et al. The Oncologist). In this study, we look at real world practice prevalence of BRCA mutations among pts with breast and/or ovarian cancer referred for testing because of positive family history (FH) and/or young age at the American University of Beirut Medical Center (AUBMC). Methods: The study was approved by the Institutional Review Board at AUBMC. We retrospectively collected clinical, radiological, pathological and genetic information on breast and ovarian cancer pts at a high hereditary risk for whom Sanger sequencing of all coding exons and immediately flanking intronic regions of BRCA1 and BRCA2 was performed between January 1, 2010 and Jan 1, 2019 at AUBMC. Between Jan 2019 and Aug 2020, Next Generation Sequencing (NGS) of 70 cancer-associated genes was referred to and done in Centogene labs (Germany). 346 subjects were included in the study; 235 pts with breast and/or ovarian cancer, and 101 subjects of young age or with a positive family history. Results: 210 pts had breast cancer (209 females, 1 male); 81 were diagnosed at age ≤40, 81 aged 41-50, and 48 aged &amp;gt;50. 185 pts had BRCA sequencing and 25 had NGS panel testing. 31 pts had ovarian cancer; 28 had BRCA testing and 3 had NGS. 3 pts had ovarian and breast cancer; all had Sanger sequencing, 1 male pt with both breast and prostate cancers had BRCA testing. The 101 subjects who were tested in the setting of positive FH of cancers or a known deleterious mutation in first degree family members were either target tested for the known familial mutation or had BRCA screening. The incidence of BRCA1 and BRCA2 mutations in women with breast cancer was 8.5% (18/210 patients) and 19.3% (6/31 patients) in women with ovarian cancer. Of the 3 pts who had both breast and ovarian cancer, 1 had a BRCA1 mutation. Almost all patients with hereditary breast cancer had a positive FH and the majority were &amp;lt; 40 years of age. 8 out of 13 BRCA1 pts had Triple Negative disease (61%). Of the 101 subjects with no history of cancer, 9 out of 30 with relatives who had BRCA1 mutation carried the same mutation, and 3 out of 15 with BRCA2 carried the mutation. The remaining 56 pts were tested because of positive FH; 3 out of 56 had a pathogenic mutation (1 BRCA1, 1 BRCA2 and 1 RAD51D). Of the 28 pts who had NGS panel sequencing, 1 patient had RAD51D, 1 had a PALB2 mutation, 1 had BARD1 and 1 had APC risk variant. Conclusions: In this real-world practice study of patients and subjects referred for germline mutation testing. BRCA mutation rate in pts with breast cancer was 8.5% (18/210) and 19% in ovarian cancer (6/31). Young age (&amp;lt; 40 years) and a positive FH are the most useful criteria to select pts with breast cancer for mutation testing, especially in the setting of limited resources. This is the first study to report a 20% rate of BRCA pathogenic variants in patients with ovarian cancer in Lebanon and Arab countries; we highlight the need to refer all ovarian cancer pts for counseling and genetic testing. NGS is important to detect mutations other than BRCA1 and BRCA2 in our population where 50% of cases are below age 50. Table 1. Incidence of BRCA1/2 mutations, age, and family history in pts with breast and ovarian cancer. Citation Format: Nagi El Saghir, Nadine Safi, Ahmad Masri, Firas Kreidieh, Deborah Mukherji, Nada Assaf, Rami Mahfouz, Hiba Moukadem. A Real-World Study of BRCA1 and BRCA2 Germline Mutations among High Hereditary Risk Subjects and Patients with Breast and Ovarian Cancer in Lebanon [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-02-17.

Multisystem inflammatory syndrome in children (MIS-C) and "Near MIS-C": A continuum?

Reports of multisystem inflammatory syndrome in children (MIS-C), following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, have been increasing worldwide, with an incidence varying significantly across studies based on the definition used for the diagnosis. At our tertiary medical center in Lebanon, we encountered several cases that presented a diagnostic challenge because they mimicked MIS-C but did not meet the US Centers for Disease Control and Prevention (CDC) definition. We decided to review these cases and describe their features in comparison with cases that met the CDC criteria of MIS-C and those that had an alternative diagnosis. This is a retrospective chart review of subjects aged <19 years old admitted to the American University of Beirut Medical Center (AUBMC) between March 1, 2020, and May 31, 2021, with suspected or confirmed MIS-C, following documented COVID-19 infection, with sufficient or insufficient criteria for diagnosis. Subjects were classified into 3 groups: "MIS-C", "Near MIS-C" and "Alternative Diagnosis". A total number of 29 subjects were included in our cohort. Fever was present in all subjects. In the MIS-C group, evidence for cardiovascular system involvement was the most common feature followed by the mucocutaneous and gastrointestinal systems. In the "Near MIS-C" and "Alternative Diagnosis" group, gastrointestinal symptoms were the most common with only one patient with cardiac abnormalities and none with coagulopathy. Subjects with typical MIS-C presentation had higher inflammatory markers when compared to subjects in the other groups. Almost all the subjects had positive IgG for SARS-CoV-2. Of the 29 subjects, the Royal College of Paediatrics and Child Health (RCPCH) case definition would have identified all suspected cases without an alternative diagnosis as MIS-C, whereas the World Health Organization (WHO) and the CDC definitions would have excluded 6 and 10 subjects, respectively. MIS-C presents a diagnostic challenge due to the nonspecific symptoms, lack of pathognomonic findings, and potentially fatal complications. More research is needed to fully understand its pathogenesis, clinical presentation spectrum, and diagnostic criteria. Based on our experience, we favor the hypothesis that MIS-C has a continuum of severity that necessitates revisiting and unifying the current definitions.

Heterogeneous Recurrence Analysis of imaged-EEG for Spatio-Temporal Epileptic Seizure Detection.

Epilepsy is known as a heterogeneous neurological disorder affecting 1 to 3 percent of the worldwide population. Epileptic seizures occur when brain cells feature abnormal synchronized recurrent activities. In this study, Heterogeneous Recurrence Analysis (HRA) is utilized to investigate seizure phenomena and to develop a spatio-temporal seizure detection algorithm. Using recurrence characteristics of multichannel scalp electroencephalography (EEG) signals we tried to model seizures by frequent feature values in neighboring channels. For this aim, some elementary features in time, frequency, and statistical domain are extracted from 2-second epochs and used to make imaged-EEGs. Each recording's channel-set provides the ground rule for placing feature values in the specified pixels in the imaged-EEGs. These images are then fed to the HRA algorithm to extract heterogeneous recurrence features in each region of the image. Despite existing methods using each individual channel's characteristics as features for each epoch, this method can provide spatial heterogeneous recurrence information for each region of the image, consequently regions of the brain. Using the HRA method with imaged-EEGs also gives us the ability to extract temporal recurrent features from successive epochs. As a result, groups of channels are considered as one region, and their recurrent behaviors in different traits are quantified as HRA features. Our method was evaluated using two publicly available epileptic EEG datasets recorded from pediatric patients at Boston Children's Hospital (CHB-MIT) and American university of Beirut Medical Center (ABMC). Considering only temporal detection of seizures, the averaged evaluation parameters are 99.6% accuracy, 99.7% sensitivity, 99.4% specificity on 24 patients of CHB-MIT dataset, and 98.5% accuracy, 97.9% sensitivity, 98.5% specificity on 6 patients of ABMC. The results show that the accuracy and specificity of the proposed method are comparable to the best machine learning baseline methods while the sensitivity is better. Besides good classification results, HRA on imaged-EEGs can give us valuable information about the patient's brain lobe/s in which recurrent features are distinctive for seizure detection.

Impact of thoracic multidisciplinary tumor boards on the management of patients with cancer: A retrospective study at the American university of Beirut medical center.

Multidisciplinary tumor boards (MDT) provide an opportunity for experts from different specialties and expertise to pool and complement each other's experience and inputs. Several factors impact the MDT discussions, including the meeting's structure, time management, and expert leadership. The process of MDT, their utilization, and efficacy need continuous assessment and improvement. A retrospective study was conducted to review the process of thoracic MDT, their plans of therapy, and changes in diagnosis and treatment plans for patients with cancer at the American University of Beirut Medical Center (AUBMC) over the period of one year. The primary outcome measure was the percentage of patients presented at the thoracic MDT who had a change in their treatment plan after the presentation. A total of 214 cases were scheduled for thoracic MDT during the study period. The majority, 132 (61.7%) did not have a treatment plan before presenting in the MDT. Of the 195 cases presented, only 43 (22.0%) did not have a change in their plan, while 88 (45.2%) of the cases presented had a change in their treatment plan. A total of 64 (32.8%) cases consisted of discussion of the diagnosis during MDT with either confirmation or modification of the patients' diagnosis. Of the 195 cases that were presented, the majority, 170 (87.2%), had their recommended treatment plan implemented after the MDT discussion. There was an association between the stage of cancer at the time of presentation and requesting additional tests (P=0.021), but there was no association between the stage of cancer and change in treatment plan (P=0.177) nor with implementation of recommendation (P=0.217). MDT are used to make upfront management decisions. In addition to considering change in management plans as an indicator of the benefit of MDT, it is suggested that making upfront multidisciplinary plans shall be considered an additional component of indicators of the benefit of MDT.