American University Of Beirut Medical Center Research Articles

The impact of young age (

BackgroundThe role of young age (< 40 years) at diagnosis as an independent risk factor for adverse outcomes in female patients with breast cancer has been highlighted in several studies. In this prospective study, we assessed the difference in 10-year survival between two groups of patients diagnosed with non-metastatic breast cancer based on an age cutoff of 40 years. We also assessed the impact of factors including tumor characteristics, molecular markers and immunohistochemical markers on survival outcomes, highlighting the interaction of those variables with age.MethodsA total of 119 female patients with newly diagnosed non-metastatic breast cancer were recruited at the American University of Beirut Medical Center (AUBMC) between July 2011 and May 2014. Patients were recruited and divided into 2 age groups (< 40 and ≥ 40 years). In addition to clinical characteristics, we assessed immunohistochemistry including estrogen, progesterone and HER2 receptors, p53, cyclin B1, vascular endothelial growth factor receptor (VEGFR), and ki-67. Germline BRCA mutations were also performed on peripheral blood samples. Patient and tumor characteristics were compared between the age groups. 10-year overall survival (OS) and disease-free survival (DFS) were estimated accordingly. Cox regression analysis was performed in order to assess the effect of the different variables on clinical outcomes.ResultsAfter a median Follow-up of 96 (13–122) months, the estimated 10-year OS was 98.6% for patients ≥40 as compared to 77.6% in patients < 40 (p = 0.001). A similar trend was found for 10-year DFS reaching 90% for patients ≥40 and 70.4% for those < 40 (p = 0.004). On multivariate analysis for DFS and OS, only younger age (< 40 years), higher stage and triple negative phenotype among other parameters assessed significantly affected the outcome in this cohort.ConclusionThis prospective study confirms the association between younger age and adverse survival outcomes in patients with non-metastatic breast cancer. Future studies of the whole genome sequences may reveal the genomic basis underlying the clinical differences we have observed.

Lebanese Hospital-Based Rheumatoid Arthritis Registry: Characteristics of Patients and Comparison with Other Populations.

Objectives:The aim of the Lebanese hospital-based Rheumatoid Arthritis (RA) registry, initiated in 2011, is to evaluate the safety and efficacy of biologic agents among patients seeking care at the American University of Beirut Medical Center (AUBMC). We aimed to characterize the demographic and clinical profile of RA patients included in the Lebanese registry. We compared our results with those issued from Middle Eastern and non-Middle Eastern registries.Methods:195 Patients enrolled in the RA registry from 2011 to 2018 were considered in this study. Patients enrolled in the registry were eligible to be treated with biologics, but 56 patients remained biologics naïve. Patients were reassessed every six months.Results:The highest proportion of patients were female (81%). The mean age was 55.53±15 years, and the disease duration was 11.38±7.7 years. RA was diagnosed at a mean age of 44.13±16 years. Almost one-third of RA patients were smokers (29.2%) and 15% consumed alcohol. Comorbidities included cardiac diseases (30.8%), hypertension (24.6%), hyperlipidemia (11.8%), diabetes mellitus (9.2%), and Hypothyroidism (6.2%). Three cases of cancer and seven cases of tuberculosis were reported. The mean of the Disease Activity Score (DAS28) was 3.75 ± 2.28 with no difference according to gender; the mean of the Health Assessment Questionnaire (HAQ) score showed a significant difference between females and males (1.02 ± 0.84 and 0.61 ± 0.7 respectively). Methotrexate was the most commonly used medication. There was non-significant difference in taking biologics according to gender.Conclusion:Our findings are similar to other studies in terms of gender distribution. The higher mean age at diagnosis compared to other populations could indicate a delay in seeking appropriate care. The Lebanese RA registry provides valuable data on pharmacological interventions used and an opportunity to follow up to examine the effectiveness of different therapeutics and to monitor their side effects.

The Role of Angiotensin Converting Enzyme 1 Insertion/Deletion Genetic Polymorphism in the Risk and Severity of COVID-19 Infection.

Background: Individuals infected with the COVID-19 virus present with different symptoms of varying severity. In addition, not all individuals are infected despite exposure. Risk factors such as age, sex, and comorbidities play a major role in this variability; however, genetics may also be important in driving the differences in the incidence and prognosis of the disease. An Insertion/Deletion (I/D) polymorphism in the ACE1 gene (rs1799752) may explain these genetic differences. The aims of this study were to determine the potential role of ACE1 I/D genetic polymorphism in the risk of contracting COVID-19 as well as predicting the severity of COVID-19 infection.Methods: Three-hundred and eighty-seven non-related Lebanese subjects, 155 controls and 232 cases, who presented to the American University of Beirut Medical Center (AUBMC) for COVID-19 PCR testing were recruited. Clinical data were collected via filling a questionnaire and accessing the medical records. Peripheral blood was withdrawn for DNA isolation, and genotyping performed with standard PCR followed by band visualization on agarose gel.Results: In our study population, previously described risk factors such as gender, age, and comorbidities were associated with increase in disease susceptibility and severity. ACE1 I was the least common allele, and there was a positive association between ACE1 I and the risk of contracting the COVID-19 disease. More specifically, the frequency of II genotype was significantly higher among cases when compared to controls (P = 0.035) with individuals with the II genotype having greater risk for contracting the COVID-19 disease: OR = 2.074, P = 0.048 in the multivariate analysis. As for disease severity, the DD genotype and D allele were associated with increased risk for developing severe symptoms (OR = 2.845, P = 0.026 and OR = 2.359, P = 0.014, respectively), and the DD genotype with necessitating hospitalization (OR = 2.307, P = 0.042). In parallel, D allele carriers showed a significantly increased risk for developing hypoxia: OR = 4.374, P = 0.045.Conclusion: We found a positive association between ACE1 I and the risk of contracting the COVID-19 disease, and between ACE1 D and a worse outcome of the COVID-19 infection. Therefore, genotyping for ACE1 I/D polymorphism could be used to assess risk and predict severity for better prognosis and management of the disease.

Physicians\u2019 approach to end of life care: comparison of two tertiary care university hospitals in Lebanon

BackgroundThe care of terminally ill patients is fraught with ethical and medical dilemmas carried by healthcare professionals. The present study aims to explore the approaches of Lebanese attending physicians towards palliative care, end of life (EOL) care, and patient management in two tertiary care university hospitals with distinct medical culture.MethodsFour hundred attending physicians from the American University of Beirut Medical Center (AUBMC) and Hotel Dieu de France (HDF) were recruited. Participants were Medical Doctors in direct contact with adult patients that could be subject to EOL situations providing relevant demographic, educational, religious as well as personal, medical or patient-centric data.ResultsThe majority of physicians in both establishments were previously exposed to life-limiting decisions but remains uncomfortable with the decision to stop or limit resuscitation. However, physicians with an American training (AUBMC) were significantly more likely to exhibit readiness to initiate and discuss DNR with patients (p<0.0001). While the paternalistic medicinal approach was prevalent in both groups, physicians with a European training (HDF) more often excluded patient involvement based on family preference (p<0.0001) or to spare them from a traumatic situation (p=0.003). The majority of respondents reported that previous directives from the patient were fundamental to life-limiting decisions. However, the influence of patient and medical factors (e.g. culture, religion, life expectancy, age, socioeconomic status) was evidenced in the HDF group.ConclusionEarly physician-initiated EOL discussions remain challenged in Lebanon. Paternalistic attitudes limit shared decision making and are most evident in European-trained physicians. Establishing a sound and effective framework providing legal, ethical and religious guidance is thus needed in Lebanon.

Amblyopia risk factors among pediatric patients in a hospital-based setting using photoscreening.

The aim of our study was to determine the prevalence of amblyopia risk factors in children visiting the American University of Beirut Medical Center (AUBMC) using automated vision screening. This was a hospital-based screening of 1102 children aged between 2 and 6 years. Vision screening was performed using PlusoptiX S12 over 2 years (2018-2020). The need for referral to a pediatric ophthalmologist was based on the amblyopia risk factors set forth by the American Association for Pediatric Ophthalmology and Strabismus. Referred patients underwent a comprehensive eye examination. A total of 1102 children were screened, 63 were referred for amblyopia risk factors (5.7%); 37/63 (59%) underwent comprehensive eye examination and 73% were prescribed glasses. Of the non-referred group of children, 6.35% had astigmatism, 6.25% were hyperopic and 3.27% were myopic. The refractive errors observed among the examined patients were distributed as follows: 41% astigmatism, 51% hyperopia, and 8% myopia; amblyopia was not detected. Refractive amblyopia risk factors were associated with the presence of systemic disorders. Bland-Altman plots showed most of the differences to be within limits of agreement. Using an automated vision screener in a hospital-based cohort of children aged 2 to 6 years, the rate of refractive amblyopia risk factors was 5.7%. Hyperopia was the most commonly encountered refractive error and children with systemic disorders were at higher risk.

Sequential Regimen with Thiotepa, Cyclophosphamide, Etoposide, Fludarabine and Busulfan in Allogeneic Stem Cell Transplantation for the Treatment of Relapsed and Refractory Hematological Malignancies

INTRODUCTION: Relapsed / Refractory leukemia and lymphoma (R/R, L/L) patients have a very poor prognosis despite all the well-known therapeutic strategies. Sequential conditioning followed by allogeneic stem cell transplantation (allo-SCT) provides an efficient disease control in those high risk patients.PATIENTS AND METHODS: we conducted a retrospective study at the American University of Beirut medical center (AUBMC) to assess the safety and efficacy of sequential conditioning in patients with R/R, L/L undergoing allo-SCT. We included 14 consecutive patients with (R/R, L/L) who received sequential conditioning followed by allogeneic stem cell transplantation (allo-SCT) from either matched related or haploidentical donors from April 2015 to May 2017. At time of transplantation patients included in the study were either in progressive disease (PD) or complete remission 2 (CR2), or partial remission (PR) after many lines of treatment. The study was approved by the institutional review board of American University of Beirut Medical Center. All patients received the following conditioning regimen of sequential chemotherapy: Thiotepa intravenous (IV) (5mg/kg/day) on days -13 and -12, Cyclophosphamide IV (400mg/m2/day) from day -11 to day -8 , Etoposide IV (100mg/m2/day) from day -11 to day-8, Fludarabine IV (30mg/m2/day) from day -5 to day-1, Busulfan IV (130mg/m2/day) on days -5 and -4 and ATG (thymoglobuline) IV 2,5 mg/kg on days -2 and -1 , followed by peripheral stem cells infusion on day 0. All patients characteristics, infectious complications and outcomes are listed in Table1.The primary outcomes weresafety and efficacy of this new sequential conditioning in allo-SCT. Secondary outcomes included engraftment, chimerism, acute and chronic graft versus host disease (GVHD), infections and relapse on days +30, +100 and 1 year post allo-SCT.RESULTS: After a median follow up of 7 months (range, 2-23) post-allo-SCT, all patients had neutrophil engraftment after a median time of 14 days (range, 10-20), and 13 patients had platelets engraftment after a median time of 15 days (range, 10-100). One patient failed to have platelets engraftment. At the time of last follow up, 9 patients (64%) were alive with complete remission (CR), with a median follow up of those of 7 months (range,2-23); four of whom had progressive disease (PD) at time of transplantation. Five patients who had PD at time of transplantation died. Of those, three (21%) died due to disease relapse that occurred at a median time of 152 days post allo-SCT (range, 60-296). The other two (14%) patients died because of transplant related mortality, one because of veno occlusive disease and one because of infection while were in CR. The cumulative incidence of Grade II-IV acute GVHD was 21%. Three patients (21%) developed chronic GVHD. The median progression free survival (PFS) and the median overall survival (OS) were not reached. All the complications and outcomes post allo-SCT are listed in table 1.CONCLUSIONS: Our results indicate that this sequential conditioning regimen appears to be feasible, with low TRM, allows high rate of engraftment and good disease control among high-risk patients. Further large prospective trials needed to evaluate that. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Comparison Between Liver Stiffness Measurement by Fibroscan and Splenic Volume Index as NonInvasive Tools for the Early Detection of Oxaliplatin-induced Hepatotoxicity

Oxaliplatin remains an essential component of many chemotherapy protocols for gastrointestinal cancers; however, neurotoxicity and hepatotoxicity may be dose-limiting. The gold standard for the diagnosis of oxaliplatin-induced hepatotoxicity is liver biopsy, which is invasive and costly. Splenomegaly has also been used as a surrogate for liver biopsy in detecting oxaliplatin-induced sinusoidal obstruction syndrome (SOS), but splenic measurement is not routine and can be inaccurate and complex. We investigated the correlation between increased liver elasticity assessed by Fibroscan and the increase in spleen volume on cross-sectional imaging after oxaliplatin as a noninvasive technique to assess liver stiffness associated with oxaliplatin-induced SOS. Forty-six patients diagnosed with gastrointestinal cancers and planned to take oxaliplatin containing regimens were included in this prospective study at the American University of Beirut Medical Center (AUBMC). Measurement of spleen volume using cross-sectional imaging and of liver elasticity using Fibroscan was performed at baseline, 3 and 6 months after starting oxaliplatin. Mean liver elasticity measurements were compared between patients stratified by the development of splenomegaly using the Student t-test. Splenomegaly was defined as 50% increase in spleen size compared with baseline. Patients who developed splenomegaly afteroxaliplatin use had significantly higher mean elasticity measurements as reported by Fibroscan at 3(16.2vs. 7.8kPa, P= 0.036) and 6 (9.3 vs. 6.7kPa, P= 0.03) months. Measurement of elasticity using Fibroscan could be potentially used in the future as a noninvasive test for predicting oxaliplatin-induced hepatotoxicity.

Outcomes of patients with malignancy admitted to the intensive care units (ICU): A prospective study.

e24001 Background: An important aspect of improving outcomes for patients with malignancy is the provision of critical care during periods of acute deterioration. Decisions regarding whether advanced cancer patients should be admitted to the ICU is based on a complex suite of considerations, including short- and long-term prognosis, quality of life, and therapeutic options to treat cancer. We set to describe demographic, clinical, and survival data and to identify factors associated with short- and long-term mortality in critically ill advanced cancer patients with non-elective admissions to general ICUs. Methods: Critically ill adult (≥18-year-old) cancer patients non-electively admitted to the intensive care units at the American University of Beirut Medical Center (AUBMC) between August 1st, 2015, and March 1st, 2019, were included. Demographic, clinical, and laboratory data was prospectively collected from first day of ICU admission up to 30 days after discharge. This study was strictly observational and clinical decisions were left to the discretion of the ICU team and attending physician. Results: Two hundred seventy-two patients were enrolled in the study between August 1st, 2015, and March 31st, 2019, with an ICU mortality rate of 43.4%, with the number rising to 59% within 30 days of ICU discharge. Mean length of stay in our ICU was 14 days with an interquartile range of 1 to 120 days with a median overall survival of 22 days since date of ICU admission. The major reasons for unplanned ICU admission were sepsis/septic shock (54%) and respiratory failure (33.1%). COX regression analysis showed that sepsis, uncontrolled malignancy, ARDS, multi-organ failure, use of vasopressors, use of mechanical ventilation are major predictors of poor prognosis. Direct admission from the ED was associated with a higher risk of mortality (48.9%) than being transferred from the floor (32.6%) (p = 0.014). Additionally, mortality in patients with solid malignancies (47.6%) was higher than those with hematologic malignancies (34.1%) (p = 0.0048). Conclusions: Patients admitted to the ICU in a tertiary care center in the MENA region are at high risk for short term mortality.

Radiation levels following the Beirut seaport explosion: environmental survey and public dose exposure.

On August 4, 2020, an explosion at the Port of Beirut, Lebanon, ripped the city to shreds, killing more than 200 people, wounding 6500 others, and leaving about 300,000 residents temporarily homeless. The explosion raised many concerns regarding the possible presence of radioactive material and the associated public health risks. Accordingly, and after opening the affected sites for public access, an external radiological survey of the hit area was conducted. The dose rate reading in Beirut's seaport (ground zero) varied between 58 and 100nSv/h. The detected levels were within the average worldwide annual gamma dose rate of 50 to 53nSv/h set by the United Nations Scientific Committee on the Effects of Atomic Radiation. The recorded values were not significantly different from those measured by the Lebanese Atomic Energy Commission (LAEC) at the National Council for Scientific Research (CNRS-L) in 2009 and 2010 at three locations in Beirut's seaport (minimum value 50nSv/h and maximum value 140nSv/h). Besides, in the surveyed area, radiological scans were conducted on 360 injured patients reported to the American University of Beirut Medical Center (AUBMC), showing no signs of radiation exposure due to the explosion.

Occupational Exposure to Blood-Borne Pathogens among Healthcare Workers in a Tertiary Care Center in Lebanon

Despite numerous initiatives, occupational exposure to blood-borne pathogens (BBP) caused by percutaneous injuries or mucosal contamination remain common among healthcare workers (HCWs). These exposures were decreasing at the American University of Beirut Medical Center (AUBMC) in the previous decades. Recently, the medical center activity has been increasing with higher number of interventions performed and shorter hospital stay. Our aim was to determine the trend of incidents resulting from BBP exposures at AUBMC from 2014 till 2018 and identify whether the increase in hospital activity affected the rate of these exposures. We also aimed to assess the risk factors associated with needle stick injuries (NSIs). A retrospective observational descriptive study of all exposures to BBPs among HCWs reported to the Environmental Health, Safety, and Risk Management department at the AUBMC between 2014 and 2018 was performed. There were 967 exposures reported among which 84% were due to needlesticks. Residents (40%), followed by nurses (30%), and then by attending physicians (16%) were the top three most exposed occupational groups. Half of the participants injured themselves using either a syringe or a suture needle; and mostly during or after use. Occupation and incident location were associated with NSIs. The mean BBP exposure incidence rate was 5.4 per 100 full-time employees, 65.6 per 100 bed-years, and 0.48 admission-years. The BBP exposure rate per 100 occupied beds per year decreased between 2014 and 2017 then increased in 2018 (P < 0.001). The number of BBP exposures showed a strong, though non-significant negative correlation with the average length of hospital stay (Spearman correlation coefficient = -0.9, P = 0.083). BBP exposure remains a serious occupational hazard. Our study shows that the BBP exposure rate per 100 occupied beds per year started decreasing during the study period before increasing again in 2018. Only the nursing department showed a consistent decrease of exposures. The occupation and incident location were found to be risk factors associated with NSIs. In addition to providing education and training, additional steps such as providing safety equipment and future interventions directed towards adjusting to higher workload should be all considered.

Arrhythmias in Neonates and Infants at a Tertiary Care Center

BackgroundLimited data about arrhythmias in neonates and infants are coming out from the Middle East.ObjectivesTo evaluate different types of arrhythmias in neonates and infants at the American University of Beirut Medical Center (AUBMC), a tertiary care center in Lebanon, with the focus on the nature of arrhythmia, treatment modalities and relation to surgery.MethodsData were collected retrospectively from the hospital records. We included all neonates and infants presenting to AUBMC between 2013 and 2017. Collected data included: the type of arrhythmia, the treatment modality used and its success, the need for additional modes of treatment, the relationship to congenital heart diseases, and the cardiac surgeries performed.ResultsOf 16,346 subjects admitted to AUBMC between 2013 and 2017, 90 subjects developed arrhythmias that required medical intervention. The most frequent types of arrhythmias were supraventricular tachycardia (62.22%), junctional ectopic tachycardia (13.33%), complete heart block (7.78%), atrial flutter (5.56%), multifocal atrial tachycardia (3.33%), Wolf Parkinson White Syndrome (3.33%), non-sustained ventricular tachycardia (2.22%), sinus pause (1.11%), and premature ventricular contractions (1.11%). Bivariate analysis showed a significant difference between arrhythmias not related to cardiac surgery and arrhythmias related to cardiac surgery in terms of the type of arrhythmia developed, the presence of congenital heart defect, prematurity, and electrolyte disturbances (P-value <0.005). However, multivariate logistic regression showed no significant difference between the two groups after adjustment for the significant variables (P-value > 0.05).ConclusionThere is a significant difference between arrhythmias not related to cardiac surgery and arrhythmias related to cardiac surgery in neonates and infants at AUBMC. However, the difference disappears after adjusting for different variables.

Waterpipe Smoking among Bladder Cancer Patients: A Cross-Sectional Study of Lebanese and Jordanian Populations.

Background Bladder cancer (BC) is the second most reported cancer in Lebanon and the fifth in Jordan. Its risk factors are mainly smoking and occupational exposure to aromatic amines. In these countries where smoking and bladder cancer are highly prevalent, the role of waterpipe smoking (WPS) in bladder cancer is less investigated. We aim to compare two sets of patients between Lebanon and Jordan, focusing on their smoking habits, WP use, occupational exposure, and the grade/invasiveness of their bladder cancer. Methods This is a cross-sectional study that compares the smoking culture between two sets of populations with bladder cancer, from two different countries. We recruited 274 bladder cancer patients over the 18 years of age at the American University of Beirut Medical Center (AUBMC), and 158 bladder cancer patients over the age of 18 years at the King Hussein Cancer Center (KHCC). Results 7.7% of Lebanese patients had significantly more positive family history of bladder cancer compared to 13.9% of Jordanian patients (p = 0.045). Another significant finding is that the majority of Lebanese patients 70.7% reported being frequently exposed to secondhand smoking, mainly cigarettes, versus only 48.6% of Jordanian patients (p < 0.001). The increasing smoking trend among Lebanese females is remarkably the highest in the region, which contributed to the overall increase in smoking rates in the country. 17.1% of the Lebanese smoking patients are mainly but not exclusively WP smokers of which 6.3% are daily WP smokers, similarly 17.1% of the Jordanian patients of which 3.2% are daily WP smokers. There were 71.5% of Lebanese patients who had a noninvasive BC versus 40% of Jordanian patients (p < 0.001), and more than one-third reported an occupational exposure to one of the risk factors of BC in both groups. Conclusions Bladder cancer incidence is on the rise in both Jordan and Lebanon along with different smoking types. It is necessary to impose prevention policies to prevent and control the high smoking prevalence. Bladder cancer invasiveness is higher in Jordan compared to universal data.

The impact of age on prognosis in patients with gastric cancer: experience in a tertiary care centre.

Gastric cancer (GC) is a leading cause of cancer-related death in the world and most patients have advanced disease upon presentation. The effect of age on prognosis in GC is controversial. We aimed to determine the impact of age on survival in patients with GC. This was a retrospective study of the medical records of Lebanese patients diagnosed with GC at the American University of Beirut Medical Center (AUBMC) between 2005 and 2014. Patients were divided into young (<65 years) and older groups (≥65 years). A multivariate analysis was done to determine the independent predictors of survival. Kaplan-Meier method was used for analysis of long-term survival outcomes. The sample consisted of 156 patients. The mean age was 62.15 (SD 13.54). Most patients presented with stage 4 disease (62.2%) and poorly differentiated histology (66.4%). The most common symptoms were abdominal pain and weight loss. On bivariate analysis, advanced stage (P=0.02) and higher grade (P=0.04) were associated with increased mortality. Patients <65 years of age were significantly more likely to have poorly differentiated tumours, while patients ≥65 years had more comorbidities (P=0.001). The 5-year DFS were 35% and 37% for patients <65 years of age and ≥65 years of age, respectively (P=0.15). Higher grade and advanced stage are associated with worse survival in patients with GC, but age did not seem to have an impact. Screening high risk patients and early diagnosis are necessary to improve survival.

Safety and Efficacy of Replacing Vindesine with Vincristine in R-ACVBP Protocol for the Treatment of High-Grade B Cell Lymphoma

Background: Intensified immunochemotherapy with rituximab, doxorubicin, cyclophosphamide, vindesine, bleomycin, and prednisone (R-ACVBP) has been shown to improve outcomes in younger adults with high-grade B-cell lymphomas (hg-BCL) when compared to standard therapy with R-CHOP (Cyclophosphamide-Adriamycin-Vincristine-Prednisone) (Recher C. Lancet 2011). Due to unavailability of vindesine at our institution, we primarily aimed at assessing the safety and efficacy of replacing vindesine with vincristine in a modified R-ACVBP protocol (mR-ACVBP). Secondary endpoints included progression-free survival (PFS), and overall survival (OS). Methods: This is a retrospective study performed at the American University of Beirut Medical Center (AUBMC), Lebanon, including all consecutive adult patients (pts) with newly diagnosed hg-BCL who received first-line mR-ACVBP from 10/2014 to 10/2019. mR-ACVBP protocol was similar to published original protocol with the exception of vindesine being replaced by vincristine 1.5 mg intravenously on days 1 and 5 of each cycle (initial protocol included vincristine 2 mg on days 1 and 5, later adjusted for toxicity). Pts were assessed for response after 4 cycles of mR-ACVBP. Responders continued with consolidation consisting of 2 cycles of high-dose methotrexate followed by 4 cycles of Rituximab-Ifosfamide-Etoposide then low-dose cytarabine x2. Pts with inadequate response on interim imaging were offered consolidative autologous stem cell transplantation (ASCT). Incomplete responders after 4 cycles (CR defined as delta SUVmax more than 70%) were shifted to salvage therapy including R-ICE (Rituximab, Ifosfamide, Cytarabine, Etoposide), or R-DHAP (Rituximab, Dexamethasone, Cytarabine, Cisplatin). Pts with age-adjusted IPI ≥ 2 could receive consolidative ASCT at the physician's discretion. Results: We identified 56 pts with hg-BCL, with a median age of 41 years [range: 21-67]. 64% of patients were males. 45 (80%) pts had advanced stage (III/IV), and 37 (66%) pts had an age-adjusted-IPI score &amp;gt;1. Fifty-one pts were evaluable for response after 4 cycles by PET CT scan. The overall response rate was achieved in 46 (90%) pts; complete response (CR) in 41 (80%), partial response (PR) in 5 (10%), 2 of which considered to have inadequate response as per delta SUVmax. 12 (27%) pts received consolidative ASCT, 27 (61%) continued consolidation chemotherapy, and 5 (11%) pts received subsequent salvage treatment. The most common reported treatment emergent adverse events, encountered during induction mR-ACVBP, were anemia (n=51, 91%), followed by febrile neutropenia (n=36, 64%, grade 4 in 26 (46%) pts, of whom four required intensive care monitoring), thrombocytopenia (n=22, 39%), and mucositis (n=12, 21%). Peripheral neuropathy was encountered in 7 (12%) pts (grade 1, n=2, grade 2, n=4, grade 3, n =1). Two deaths were attributed to treatment due to febrile neutropenia and septic shock during first and third cycle of mR-ACVBP in patients who had an aaIPI of 3. After a median follow up of 17 months [range, 0.5-55], a total of 4/44 (9%) pts progressed, 3 while on treatment after high-dose methotrexate, 1 after therapy completion. The median PFS and OS were not reached. The 2-year PFS and OS were 86% and 87% respectively. At last follow up, 47 pts were alive (44 (94%) pts were in continuous CR, 1 (2%) pt in PR and 2 (4%) pts progressive disease), 6 pts died, and 3 were lost to follow up. Conclusion: The use of vincristine in mR-ACVBP instead of vindesine seems to be feasible, with acceptable manageable adverse events. Despite higher risk disease, survival rates seem to be comparable to published data of the original R-ACVBP protocol. Disclosures No relevant conflicts of interest to declare.

Grading reflective essays: the reliability of a newly developed tool- GRE-9

BackgroundThe main objective of this study is the development of a short reliable easy-to-use assessment tool in the aim of providing feedback to the reflective writings of medical students and residents.MethodsThis study took place in a major tertiary academic medical center in Beirut, Lebanon. Seventy-seven reflective essays written by 18 residents in the department of Family Medicine at the American University of Beirut Medical Center (AUBMC) were graded by 3 raters using the newly developed scale to assess the scale reliability. Following a comprehensive search and analysis of the literature, and based on their experience in reflective grading, the authors developed a concise 9-item scale to grade reflective essays through repeated cycles of development and analysis as well as the determination of the inter-rater reliability (IRR) using intra-class correlation coefficients (ICC) and Krippendorff’s Alpha.ResultsThe inter-rater reliability of the new scale ranges from moderate to substantial with ICC of 0.78, 95% CI 0.64–0.86, p < 0.01 and Krippendorff’s Alpha was 0.49.ConclusionsThe newly developed scale, GRE-9, is a short, concise, easy-to-use reliable grading tool for reflective essays that has demonstrated moderate to substantial inter-rater reliability. This will enable raters to objectively grade reflective essays and provide informed feedback to residents and students.

CLL-358: First-Line Treatment of Hairy Cell Leukemia with Cladribine Followed by Rituximab Consolidation Significantly Improves Leukemia-Free Survival

Context Purine analogue therapy remains the standard of care in hairy cell leukemia (HCL) management. Despite high remission rates, many patients subsequently relapse and require re-treatments. Objective The aim of this study is to compare the effectiveness and safety of cladribine vs. cladribine followed by rituximab consolidation as first-line therapy of HCL. Design This is a retrospective study including all consecutive patients with classical HCL treated and followed at the American University of Beirut Medical Center (AUBMC) between 2000 and 2019. Methods We identified 29 HCL patients, with a median age of 50.5 (range: 30–71) years. Patients were divided into two cohorts based on treatment received: cohort A (N=14) received cladribine 5.6 mg/m2 intravenously (IV) for 7 days as a single agent, and cohort B (N=15) received the same dose of cladribine followed by rituximab 375 mg/m2 IV weekly for eight doses. Rituximab consolidation was given after a median time of 33 days (17–60 days) from cladribine completion. Complete remission rates were 64% and 100% in cohorts A and B, respectively. In cohort A, seven (50%) patients relapsed after a median duration of 48 months (range: 1–209 months), requiring second-line treatment with cladribine followed by rituximab. In cohort B, no relapses occurred. After a median follow up of 67 months (range: 1–227 months), the 5-year disease-free survival was significantly better in group B (100%) compared to group A (58%) (HR=0.16, 95% CI: 0.032–0.84, p=0.03). There was no significant difference in overall survival between the two groups. Grade 3/4 adverse events were observed in 92%% and 80% of patients in cohorts A and B, respectively, mainly neutropenia (78.5% vs 66.6%) and febrile neutropenia (71% vs. 40%). One patient in cohort B who received rituximab consolidation too early (day 17) died from febrile neutropenia and septic shock. Conclusion Consolidation rituximab after cladribine in frontline treatment of classical HCL showed high response rate of 100% and translated into a significant improvement in disease-free survival. Cladribine followed by rituximab consolidation may be considered as standard first-line therapy of HCL.

Pediatric posterior fossa tumors outcomes: Experience in a tertiary care center in the Middle East

BackgroundAmong all childhood cancers, brain tumors are second only to leukemia in incidence and are the most common solid pediatric tumors. More than 60 % of pediatric brain tumors are infra-tentorial. The first-line treatment for most infra-tentorial tumors in pediatric patients is surgical resection, with the goal of gross-total resection, relief of symptoms and hydrocephalus, and increased survival. The proximity to the fourth ventricle, and therefore, the cerebrospinal fluid (CSF) pathways, predisposes children with posterior fossa tumors to the development of obstructive hydrocephalus and multiple other co-morbidities pre and post-surgery. ObjectivesThis study aims to present our series of pediatric posterior fossa tumor surgeries in the Neurosurgical Department at the American University of Beirut Medical Center(AUBMC) and perform internal quality control for our single-institution consecutive series as one of the largest referral and tertiary care centers in the region. The second purpose of this retrospective study is to weigh the risks of surgery against the presumed advantages and to have specific knowledge about the complication rates, especially those related to the CSF pathway, comparing our results to those in the literature. MethodsAll pediatric patients (< 18 years of age), referred to our center from different regions in the middle east, and surgically treated for a posterior fossa tumor from June 2006 to June 2018 at the American University of Beirut Medical Center were included. A thorough review of all medical charts was performed to validate all the database records. ResultsThe patient sample consisted of 64 patients having a mean age of 6.19 ± 4.42 years and 59.37 % of whom were males. The most common tumor pathology was pilocytic astrocytoma (40.62 %) followed by medulloblastoma (35.93 %) and ependymoma. The most common type of tumor that was seen in patients that developed mutism postoperatively (n = 6, 9.37 %) was medulloblastoma (n = 4, 66.66 %). In this patient sample, 12.28 % (n = 7) of the patients developed hydrocephalus postoperatively.Midline tumors were more associated with the development of mutism(OR = 4.632, p = 0.306) and hydrocephalus (OR = 5.056, p = 0.135) postoperatively, albeit not statistically significantly.The presence of a preoperative shunt was shown to be protective against the development of CSF leak (OR = 0.636, p = 0.767), as none of the patients that came in with CSF diversion developed a CSF leak after their surgery. ConclusionThis study from a single center experience accompanied by a thorough literature review sheds light on the complications frequently encountered after posterior fossa tumor surgery in children. These included transient cerebellar mutism, CSF leak, and hydrocephalus as seen in some of our patients. Our findings highlight the need for prospective studies with well-defined protocols directed at assessing novel ways and approaches to minimize the risk of these complications.

In-situ simulations for COVID-19: a safety II approach towards resilient performance

BackgroundCOVID-19 has taken the world by surprise; even the most sophisticated healthcare systems have been unable to cope with the volume of patients and lack of resources. Yet the gradual spread of the virus in Lebanon has allowed healthcare facilities critical time to prepare. Simulation is the most practical avenue not only for preparing the staff but also for troubleshooting system’s latent safety threats (LSTs) and for understanding these challenges via Hollnagel’s safety I–II approaches.MethodsThis is a quality improvement initiative: daily in situ simulations were conducted across various departments at the American University of Beirut Medical Center (AUBMC), a tertiary medical care center in Beirut, Lebanon. These simulations took place in the hospital with native multidisciplinary teams of 3–5 members followed by debriefing with good judgment using the modified PEARLS (Promoting Excellence and Reflective Learning in Simulation) for systems integration. All participants completed the simulation effectiveness tool (SET-M) to assess the simulation. Debriefings were analyzed qualitatively for content based on the Safety Model and LST identification, and the SET-Ms were analyzed quantitatively.ResultsTwenty-two simulations have been conducted with 131 participants. SET-M results showed that the majority (78–87%) strongly agreed to the effectiveness of the intervention. We were able to glean several clinical and human factor safety I–II components and LSTs such as overall lack of preparedness and awareness of donning/doffing of personal protective equipment (PPE), delayed response time, lack of experience in rapid sequence intubation, inability to timely and effectively assign roles, and lack of situational awareness. On the other hand, teams quickly recognized the patient’s clinical status and often communicated effectively.ConclusionThis intervention allowed us to detect previously unrecognized LSTs, prepare our personnel, and offer crucial practical hands-on experience for an unprecedented healthcare crisis.

Hormone Replacement Therapy: Lebanese Women's Awareness, Perception, and Acceptance.

Objectives Hormone replacement therapy (HRT) had been the gold standard for the treatment of menopausal symptoms until the publication of the World Health Initiative (WHI) study. After the WHI study, the use of HRT changed among the physicians and patients all over the world despite newer more reassuring data. This study aimed to investigate the knowledge and attitudes of women towards HRT and the factors affecting it for better counseling. Study design. A clinic-based cross-sectional study using a survey was offered to women aged 40 years and above coming to the women's health center at the American University of Beirut Medical Center (AUBMC) from October 1st, 2017, till March 31st, 2018. The questionnaire included questions about demographics and menopausal symptoms in addition to knowledge and attitudes towards menopause and HRT. Main outcome measures. Our main hypothesis was that women would be aware of HRT as a treatment modality; however, the majority would have a negative attitude towards its usage. Results The response rate was 87.8%. Seventy-three percent of the respondents had already heard about HRT with 57.9% supporting the use of HRT; however, 47.9% did not know when to use it. The significant predictor for having heard about HRT and a positive attitude towards HRT were having HRT prescribed as a part of treatment and employment status, respectively. Conclusions Lebanese women are aware of HRT as a treatment option; however, a lack of both proper information and positive attitude towards HRT use was noted.

Diagnosis of Clostridiodes difficile infection: Assessing the performance of Quik Chek complete kit assay versus the GeneXpert PCR assay at a major tertiary care center in Lebanon

AimsTo evaluate the performance of the C. difficile Quik Chek Complete (QCC) (TechLab, USA) versus the GeneXpert C. difficile polymerase chain reaction (PCR) assay (Cepheid, CA, USA). MethodsA retrospective chart analysis conducted at the American University of Beirut Medical Center (AUBMC) covering the period from January 2015 to September 2018. ResultsA total of 788 samples were simultaneously tested by the two methods and analyzed in this study. 49% were positive with the QCC-EIA assay (GDH and/or toxins). The GeneXpert assay showed 40% positivity, based on the detection of either toxin B or binary toxin genes. Using GeneXpert as a reference test, the performance of C. difficile Quik Chek was evaluated in terms of sensitivity (96%), specificity (81%), PPV (77%) and NPV (97%). Among the concordant negative results with the QCC-EIA assay (GDH−/Toxins-), 97% were negative by GeneXpert, while among the concordant positive results (GDH+/Toxins+), 92% were positive by GeneXpert. Regarding the discordant QCC-EIA results (GDH+/Toxins-), 77% were positive by PCR. ConclusionC. difficile Quik Chek immunoassay is a solid method to use as an upfront for stool testing of C. difficile infections with satisfactory sensitivity and specificity when compared to GeneXpert assay. When results of the immunoassay are concordant for both the toxins and GDH components, it is very unlikely for the results to be different with molecular assays such as the GeneXpert. However, for discordant results, we recommend following up such cases with a molecular assay like GeneXpert.