Hospitals In Lebanon Research Articles

In-hospital Neonatal Mortality and the Role of Consanguinity

Consanguinity which increases the risk of genetic disorders has been implicated at times in infant mortality. The aim of this study was to determine the association between consanguinity and in-hospital mortality in newborns. Data was collected prospectively on all births from 26 hospitals in Lebanon from January 2004 to December 2008 and admitted to the National Collaborative Perinatal Neonatal Network. Secondary analysis was done on 65,402 singletons, after exclusion of stillbirths, infants of multiple gestation and infants of second cousin progeny. In-hospital mortality was 6.7 per 1000 live births (439/65,402). The rate of first cousin marriage was 9.9%. Consanguinity was significantly associated with in-hospital mortality (odds ratio 2.4; 95% confidence interval (CI): 1.8, 3.1); consanguinity remained a significant predictor of mortality (odds ratio 1.8 [95% CI: 1.2, 2.9]) after adjusting for maternal age and education, crowding index, history of abortion, prenatal care, mode of delivery, gender, birthweight and apgar score at 5 minutes. This association of consanguinity with in-hospital mortality points to potential genetic factors leading to this increased risk. Designing public health interventions, including raising the awareness and taking into consideration such risks in neonatal mortality studies are indicated.

Dietetic practices in adult hemodialysis units compared to k/doqi guidelines, lebanon

Hospitals in Lebanon mostly employ only one dietitian to conduct all dietetic/food service/administrative tasks including hemodialysis (HD) units which are exclusively hospital based. Little is known about dietetic practices in these (HD) units. Kidney Disease Outcomes Quality Initiative (KDOQI) and American Dietetic Association (ADA) presented evidence that the presence of a competent dietitian in the HD unit has benefits on HD patient’s health and quality of life and is cost effective. This study aimed to reveal the current practices provided by dietitians to HD patients in Lebanon compared to KDOQI nutrition guidelines. A 36 item anonymous self-administered questionnaire was sent to all HD units in Lebanon (n=55). The questionnaire included 2 sections: 1) demographics and professional characteristics; 2) routine clinical practice Thirty eight (69%) of the dietitians responded; only 34 were of use. The questions in survey were categorical, thus only the answers with the majority of the respondents will be reported: 97% were female. 82% were within the age of 21–34, 62% had 3–10 years in clinical practice and 44% had only 0–2 years exposure to renal patients. Most dietitians (69%) worked in hospitals with 50–150 inpatients and 26–75 HD patients. Sixty nine percent of dietitians spent more than 36 hours per week in the hospital, while 85% spent less than 10 hours per week in the HD unit. As to the level of applying KDOQI nutrition guidelines in routine practice, of the 23 guidelines asked, all dietitians used at least 1 guideline, 17% used 5 and 23% used 10 guidelines. Only one dietitian applied all guidelines. A total compliance to guidelines score was developed as a percentage of total compliance which showed 37±15.51% (min14, max 73). Barriers identified were lack of time and lack of integration into the medical team. It is evident that dietetic practices in Lebanon targeting HD patients need support in all aspects: time, knowledge, empowerment and training.

MMP1-1607(1G>2G) polymorphism and the risk of lung cancer in Lebanon

CONTEXT:Matrix metalloproteinases (MMPs) are a family of enzymes that degrade various components of the extracellular matrix and are involved in the development and progression of cancer. Lung cancer is the most commonly diagnosed cancer in Lebanon. MMP1 is responsible for degrading stromal collagens, which enhance the ability of neoplastic cells to cross basal membrane of both the endothelium and the vascular endothelium. A recent meta-analysis has suggested that the MMP1-1607 2G allele may be associated with an increased risk for certain types of cancers.AIM:This study was undertaken to investigate the association between guanine insertion polymorphism in the MMP1 promoter and the susceptibility to lung cancer in the Lebanese population.SETTINGS AND DESIGN:This case-control study was conducted on 41 patients with lung cancer and 51 age-matched healthy controls, recruited from different regions of Lebanon.METHODS:Cases were histologically confirmed lung cancer patients obtained from different hospitals in Lebanon. Controls were healthy unrelated individuals with no history of cancer or genetic diseases. All subjects were genotyped for MMP1 -1607(1G>2G) polymorphism using polymerase chain reaction-restriction fragment length polymorphism method (PCR-RFLP).RESULTS:No statistically significant differences were found when genotype and allele distribution of MMP1 -1607(1G>2G) polymorphism were compared between patients with lung cancer and controls [P= 0.6 by chi-squared test on a 3×2 contingency table; allelic P=0.61, OR (95% CI) = 1.18 (0.60-2.31)].CONCLUSION:Our data shows that MMP1 promoter polymorphism is not associated with lung cancer susceptibility in the Lebanese population.

Occupational Violence at Lebanese Emergency Departments: Prevalence, Characteristics and Associated Factors

Emergency departments (EDs) workers are at increased risk of exposure to occupational violence. The prevalence of occupational violence is potentially higher and consequences are more serious in areas with poor security conditions. We investigated the prevalence, characteristics and factors associated with the exposure of ED workers to violence at Lebanese hospitals. All ED employees at six tertiary hospitals in Lebanon were surveyed using a cross-sectional design. The survey instrument included four sections collecting demographic/professional information and measuring exposure to violence, degree of job satisfaction and degree of professional burnout. The questionnaire was distributed to all ED employees at participating hospitals and was completed by 256 ED workers (70.3% response rate). Multinomial and binary logistic regressions were used to investigate factors significantly associated with verbal and physical violence. Over the past 12 mo, four in five ED employees were verbally abused and one in four was physically assaulted. Exposure to verbal abuse was associated with serious outcomes including significantly higher levels of occupational burnout and an increased likelihood to quit current job. Exposure to physical violence was associated with increased likelihood-to-quit, nurse status and "public hospital" employment. Violence largely prevails at Lebanese EDs. Most vulnerable are nurses and employees of public hospitals who are disproportionally exposed to violence. ED stakeholders must work collaboratively to investigate the root causes of violence and devise and implement effective antiviolence policies and measures. Such measures will be necessary to protect the well-being and decrease the turnover of ED workers.

Toxins and Antibiotic Resistance in Staphylococcus aureus Isolated from a Major Hospital in Lebanon.

Molecular characterization of Staphylococcus aureus is of both clinical and infection control importance. Virulence determinants using PCR and multiple drug resistance profiles were studied in 130 S. aureus isolates. PCR-RFLP analysis of the 16S–23S DNA spacer region was done to investigate the level of 16S–23S ITS (internal transcribed spacer) polymorphism. Methicillin-resistant S. aureus (MRSA), which represented 72% of the studied isolates, showed multiple drug resistance with 18% being resistant to 10–18 of the drugs used compared to a maximum resistance to 9 antibiotics with the methicillin sensitive S. aureus (MSSA) isolates. Exfoliative toxin A (ETA) was more prevalent than B (ETB) with virulent determinants being additionally detected in multiple drug-resistant isolates. 16S–23S ITS PCR-RFLP combined with sequencing of the primary product was successful in generating molecular fingerprints of S. aureus and could be used for preliminary typing. This is the first study to demonstrate the incidence of virulent genes, ACME, and genetic diversity of S. aureus isolates in Lebanon. The data presented here epitomize a starting point defining the major genetic populations of both MRSA and MSSA in Lebanon and provide a basis for clinical epidemiological studies.

Dépistage du kératocône dans une population universitaire au Liban

Screening for keratoconus and potential risk factors in a medical student population in Lebanon using anterior topography. We randomly selected 110 medical students doing rotations in the Hôtel-Dieu de France hospital in Lebanon between November 2009 and February 2010. Ninety-two students agreed to participate in the screening protocol, which included a questionnaire and an anterior topography. The topography was performed using the placido disk Tomey(®) Topographic Modeling System TMS-4. The results were interpreted using the analysis programs supplied with the machine and by an experienced ophthalmologist. Ninety-two students participated in the study (83.6%): 49 males (53.2%) and 43 females (46.8%). The mean age was 23.6±1 year. Fifty-eight students were ametropic (63.1%): 44 participants were myopic (47.8%), 40 had astigmatism (43.4%), and six were hyperopic (6.5%). Three students (six eyes) were diagnosed with keratoconus. The prevalence of keratoconus was 3.3%, of which 2.2% were already known cases. The prevalence of forme frustre keratoconus was 1.1%. Eleven students (12.1%) had a family history of keratoconus, only one was diagnosed with the disease. Atopy and eye rubbing were not found significantly related to keratoconus in this population. Keratoconus is a prevalent disease among our population of Lebanese medical students, which confirms the clinical impression that keratoconus is relatively frequent in Lebanon. Further studies need to be conducted on a larger and more representative sample to assess keratoconus prevalence and risk factors in Lebanon.

Design, implementation and scaling up of the balanced scorecard for hospitals in Lebanon: Policy coherence and application lessons for low and middle income countries

Objectives This paper describes the development and implementation of the first national hospital performance indicators in Lebanon including its institutionalization within existing policy framework and the initiation of independent governance structure for sustainability. Methods Guided by the Ontario Acute Care Balanced Scorecard framework, a step-wise approach was used. Guiding principles were non-punitive reporting, anonymity, voluntary participation, stakeholder involvement, consensus and feasibility. Modified Delphi technique was used, readiness assessment surveys in 52 hospitals were conducted, pilot testing and evaluation were completed in 14 hospitals. Results Initial balanced set of 21 indicators were selected. Findings showed wide variations in indicators’ measurement in hospitals including formulas and tools. Barriers to measurement included lack of quality culture, physician resistance and resources. A gradual implementation strategy was developed and selected indicators were divided into two levels. Most piloted indicators proved to be valid, feasible and reliable. The initiative was linked to the national hospital accreditation system resulting in a balanced set of 40 indicators. An independent, not-for-profit, arm's-length organization was established. Conclusions This is among the first attempts made in the East Mediterranean Region to adapt the BSC approach and translate the experience of its development to addresses local needs and contextual reality.

Molecular epidemiological investigation of multidrug-resistant Acinetobacter baumannii strains in four Mediterranean countries with a multilocus sequence typing scheme

Thirty-five multidrug-resistant Acinetobacter baumannii strains, representative of 28 outbreaks involving 484 patients from 20 hospitals in Greece, Italy, Lebanon and Turkey from 1999 to 2009, were analysed by multilocus sequence typing. Sequence type (ST)2, ST1, ST25, ST78 and ST20 caused 12, four, three, three and two outbreaks involving 227, 93, 62, 62 and 31 patients, respectively. The genes blaoxa-58, blaoxa–23 and blaoxa-72 were found in 27, two and one carbapenem-resistant strain, respectively. In conclusion, A. baumannii outbreaks were caused by the spread of a few strains.

Consanguinity: A Risk Factor for Preterm Birth at Less Than 33 Weeks' Gestation

Consanguinity promotes homozygosity of recessive susceptibility gene variants and can be used to investigate a recessive component in diseases whose inheritance is uncertain. The objective of this study was to assess the association between consanguinity and preterm birth (PTB), stratified by gestational age and clinical presentation (spontaneous vs. medically indicated). Data were collected on 39,745 singleton livebirths without major birth defects, admitted to 19 hospitals in Lebanon, from September 2003 to December 2007. Deliveries before completed 33 weeks' gestation and deliveries at 33-36 weeks' gestation were compared, with respect to cousin marriage, with those after completed 36 weeks' gestation by using multinomial multiple logistic regression. Overall, infants of consanguineous parents had a statistically significant 1.6-fold net increased risk of being born at less than 33 weeks' gestation compared with infants of unrelated parents. This association was statistically significant only with spontaneous PTB. There was no increased risk of being born at 33-36 weeks' gestation associated with consanguinity for both clinical presentations of PTB. Our findings support a genetic contribution to early onset PTB and suggest that early PTB should be targeted in future genetic studies rather than the classic lumping of all births less than 37 weeks' gestation.

Data Envelopment Analysis Model for the Appraisal and Relative Performance Evaluation of Nurses at an Intensive Care Unit

The appraisal and relative performance evaluation of nurses are very important and beneficial for both nurses and employers in an era of clinical governance, increased accountability and high standards of health care services. They enhance and consolidate the knowledge and practical skills of nurses by identification of training and career development plans as well as improvement in health care quality services, increase in job satisfaction and use of cost-effective resources. In this paper, a data envelopment analysis (DEA) model is proposed for the appraisal and relative performance evaluation of nurses. The model is validated on thirty-two nurses working at an Intensive Care Unit (ICU) at one of the most recognized hospitals in Lebanon. The DEA was able to classify nurses into efficient and inefficient ones. The set of efficient nurses was used to establish an internal best practice benchmark to project career development plans for improving the performance of other inefficient nurses. The DEA result confirmed the ranking of some nurses and highlighted injustice in other cases that were produced by the currently practiced appraisal system. Further, the DEA model is shown to be an effective talent management and motivational tool as it can provide clear managerial plans related to promoting, training and development activities from the perspective of nurses, hence increasing their satisfaction, motivation and acceptance of appraisal results. Due to such features, the model is currently being considered for implementation at ICU. Finally, the ratio of the number DEA units to the number of input/output measures is revisited with new suggested values on its upper and lower limits depending on the type of DEA models and the desired number of efficient units from a managerial perspective.

The safety and quality of childbirth in the context of health systems: mapping maternal health provision in Lebanon

Objectiveto provide basic information on the distribution (public/private and geographically) and the nature of maternity health provision in Lebanon, including relevant health outcome data at the hospital level in order to compare key features of provision with maternal/neonatal health outcomes. Designa self-completion questionnaire was sent to private hospitals by the Syndicate of Private Hospitals in collaboration with the study team and to all public hospitals in Lebanon with a functioning maternity ward by the study team in cooperation with the Ministry of Public Health. Settingchildbirth in an institutional setting by a trained attendant is almost universal in Lebanon and the predominant model of care is obstetrician-led rather than midwife-led. Yet due to a 15-year-old civil war and a highly privatised health sector, Lebanon lacks systematic or publically available data on the organisation, distribution and quality of maternal health services. An accreditation system for private hospitals was recently initiated to regulate the quality of hospital care in Lebanon. Participantsin total, 58 (out of 125 eligible) hospitals responded to the survey (46% total response rate). Only hospital-level aggregate data were collected. Measurementsthe survey addressed the volume of services, mode of payment for deliveries, number of health providers, number of labour and childbirth units, availability of neonatal intensive care units, fetal monitors and infusion rate regulation pumps for oxytocin, as well as health outcome data related to childbirth care and stillbirths for the year 2008. Findingsthe study provides the first data on maternal health provision from a survey of all eligible hospitals in Lebanon. More than three-quarters of deliveries occur in private hospitals, but the Ministry of Public Health is the single most important source of payment for childbirth. The reported hospital caesarean section rate is high at 40.8%. Essential equipment for safe maternal and newborn health care is widely available in Lebanon, but over half of the hospitals that responded lack a neonatal intensive care unit. The ratio of reported numbers of midwives to deliveries is three times that of obstetricians to deliveries. Key conclusions and implications for practicethere is a need for greater interaction between maternal/neonatal health, health system specialists and policy makers on how the health system can support both the adoption of evidence-based interventions and, ultimately, better maternal and perinatal health outcomes.

Molecular characterization ofStaphylococcus aureusin Lebanon

Staphylococcus aureus is an important human pathogen and is a growing public health concern. In this study, 130 S. aureus, 93 methicillin-resistant S. aureus (MRSA) and 37 methicillin-sensitive S. aureus (MSSA), clinical isolates recovered from Lebanon were typed by protein A gene (spa) sequencing and multi-locus sequence typing (MLST). Forty-eight different spa types were identified and clustered into 30 different groups. MLST revealed 10 sequence types (STs) among the isolates. There were eight major MRSA clones defined as isolates with the same ST and the same SCCmec type. The majority of the PVL-positive isolates (53%) were ST80-MRSA-IVc. Systematic surveillance of both hospital and community isolates in Lebanon together with measures designed to limit the spread are required.

Design and implementation of a hospital information system for the Palestine Red Crescent Society in Lebanon

A case-mix hospital information system was designed and implemented in Palestine Red Crescent Society hospitals in order to support the network of Palestinian hospitals in Lebanon and to improve the health of refugees in the country. The system is based on routine collection of essential administrative and clinical data for each episode of hospitalization, relying on internationally accepted diagnostic codes. It is a computerized, user-friendly information system that is a stepping-stone towards better hospital management and evaluation of quality of care. It is also a useful model for the development of hospital information systems in Lebanon and in the Near East.

Triple-negative breast cancer: Epidemiology, characteristics, and survival in a Lebanese cohort

e22228 Background: Breast cancer (BC) is the most common malignancy in women in Lebanon. Triple negative (TN) phenotype is known to be associated with an increased likelihood of recurrence and death. The purpose of this study is to determine the incidence, characteristics and survival of TN BC patients in a Medical Oncology department in a University Hospital in Lebanon. Methods: We retrospectively reviewed the pathology of all women with breast cancer that were seen in our institution between 1997 and 2008. TN BC patients (pts) were defined as those that were negative for all 3 receptors (estrogen, progesterone and HER2neu on immunohistochemistry). Pts' characteristics and survival of TN women were analyzed. Results: Of the 1599 breast cancer pts, 155 (9.7%) had a triple negative phenotype. Median age was 52 years. A positive family history of breast/ovarian cancer was found in 15 pts (10%). Pathology studies showed: invasive ductal carcinoma component in 138 pts (89%), pure medullary carcinoma in 7 pts (5%), pure invasive lobular carcinoma in 6 pts (4%), pure mucinous carcinoma in 3 pts (2%) and epidermoid carcinoma in 1 pt (1%). A grade III was found in 98 of specimens (63%). Twenty-six pts (17%) presented with stage I, 73 (47%) with stage II, 37 (24%) with stage III and 19 (12%) with stage IV. Twelve percent had inflammatory breast cancer. After a median follow up of 17 months (mths), 43 pts had relapsed (5 stage I, 18 stage II and 20 stage III). The most common sites of relapse were brain (in 20 % of cases), lungs (in 20% of cases) and bone (in 11% of cases). Five- year disease free survival and 5-year overall survival were respectively 75% and 88% for stage I, 58% and 72% for stage II and 40% and 63% for stage III. Adjuvant therapy was administered to 96% of pts among which a taxane-based regimen was used in 38% of cases . Median survival for stage IV was 19 mths with a first line taxane-based regimen used in 50% of cases. Conclusions: The incidence of TN BC in Lebanon is similar to that described in the literature. It has an aggressive course. Focus on understanding the biology of this particular BC subtype is essential for determining targets for future therapeutic options. No significant financial relationships to disclose.

Elements of Evidence-based Healthcare

Elements of Evidence-based Healthcare

Antimicrobial resistance in invasive strains of Escherichia coli from southern and eastern Mediterranean laboratories

From January 2003 to December 2005, 5091 susceptibility test results from invasive isolates of Escherichia coli, collected from blood cultures and cerebrospinal fluid routinely processed within 58 participating laboratories, were investigated. These laboratories in turn serviced 64 hospitals in Algeria, Cyprus, Egypt, Jordan, Lebanon, Malta, Morocco, Tunisia and Turkey. The median proportion of resistance to third-generation cephalosporins for the duration of the project was 18.9% (interquartile range (IQR): 12.5-30.8%), and for fluoroquinolones 21.0% (IQR: 7.7-32.6%). A substantial proportion of strains reported by laboratories in countries east of the Mediterranean exhibited evidence of multiresistance, the highest proportion being from Egypt (31%). There is clearly a need for further investigation of potential causes of the significant resistance identified, as well as for strengthening of national and international surveillance initiatives within this region.;

Le circuit du médicament dans les hôpitaux libanais

Background Drug errors constitute a public health problem. The objective of our study was to describe drug circuit essential steps in the Lebanese hospitals, starting at prescription to administration, in comparison with Lebanese accreditation standards. We also evaluated technical drug errors. Methods A cross sectional study of all hospitals in Beirut and Mount Lebanon was carried out, where a pharmacist and a nurse per hospital answered anonymous standardized questionnaires. Results We found the drug circuit suffered from gaps in all 59 hospitals that were visited: doctors should increase efforts to clarify prescriptions and furnish necessary information for nurses, pharmacists better apply accreditation standards, and nurses verify and re-verify treatments before administration. Conclusion Regulatory laws are necessary for all involved actors for best responding to the responsibility in question, that is patient security.

Impact of written information on women's use of postpartum services: a randomised controlled trial

This study evaluates the impact of providing women with written educational material on their satisfaction with care, and use of health services postpartum. All women having a live birth at 4 private hospitals in Lebanon were eligible. The sample consisted of 187 women in the intervention and 191 in the control arms. An intervention booklet was developed following a qualitative study of women's information needs; placebo material was 2 leaflets about childproofing the house. Field workers administered a baseline questionnaire to recruit all eligible women, and conducted follow-up interviews 6-20 weeks postpartum at the women's residences. The written material was handed out to women just before discharge from hospital. At the baseline interview, interviewers and women were blinded to the nature of the written material. Outcome measures were a postpartum visit to a health professional after discharge and before the follow-up interview, and satisfaction with maternity care received during pregnancy, delivery and postpartum. Satisfaction with care during the postpartum period was 57.2% in the intervention and 38.9% in the control arm (p<0.001). Some 85% of women in the intervention arm had a postpartum visit compared to 55% in the control arm (p<0.001). In the context of high female literacy, the intervention is effective and requires few resources.

Survey of infection control infrastructure in selected southern and eastern Mediterranean hospitals

A structured questionnaire concerning hospital infection control (IC) organisation and initiatives was sent to 45 hospitals in Algeria, Cyprus, Egypt, Jordan, Lebanon, Libya, Malta, Morocco, Tunisia and Turkey. Hospitals bordering the eastern Mediterranean appeared to have more established IC infrastructures than southern Mediterranean hospitals. However, there were no significant differences among hospitals in the two regions in surveillance activities, the presence of an antibiotic policy or feedback of resistance data to prescribers, all of which were at a low level. Only a minority of hospitals had published antimicrobial treatment guidelines or gave feedback on antimicrobial resistance data to prescribers.

The French do health better than we do

Ionly seem to come in contact with French medicine once in three-score years. The last time before this year was in the French Hospital in Beirut, Lebanon and Syria having been French protectorates between the two world wars.