Tertiary Care Center In Lebanon Research Articles

Incidence, Risk Factors and Outcomes of Subarachnoid Hemorrhage in a Tertiary Care Center in Lebanon: a Cross-Sectional Retrospective Study

Incidence, Risk Factors and Outcomes of Subarachnoid Hemorrhage in a Tertiary Care Center in Lebanon: a Cross-Sectional Retrospective Study

Emergency Medical Services Utilization and Outcomes of Patients with ST-Elevation Myocardial Infarction in Lebanon

BackgroundArrival of patients with ST-elevation myocardial infarction (STEMI) by Emergency Medical Services (EMS) results in shorter reperfusion times and lower mortality in developed countries. ObjectivesThis study examines EMS use by STEMI patients in Lebanon and associated clinical outcomes. MethodsA retrospective observational study with chart review was carried out for STEMI patients arriving to the Emergency Department of a tertiary care center in Lebanon between January 1, 2013 and August 31, 2016. A descriptive analysis was done and followed by a bivariate analysis comparing two groups of patients (EMS vs. Non-EMS). ResultsA total of 280 patients were included in the study. They were mostly male (71.8%). Mean age was 65.1 years (95% confidence interval [CI] 63.4–66.9). Only 12.5% (95% CI 8.6–16.4) presented by EMS. Chest pain (81.1%) was the most common presenting symptom. Anterior myocardial infarction was the most common electrocardiogram (ECG) diagnosis (51.4%). Most patients were admitted (98.2%), and 72.0% of these patients were treated with primary percutaneous coronary intervention. Cardiogenic shock was the most frequent in-hospital complication (6.2%). The mortality rate was 7.1%. Mean door-to-ECG and door-to-balloon times were 10.8 (95% CI 7.1–14.4) min and 106.2 (95% CI 95.9–116.6) min, respectively. Patients’ characteristics, presenting symptoms, outcomes, and performance metrics were similar between the two groups. ConclusionEMS is underutilized by STEMI patients in Lebanon and is not associated with improvement in clinical outcomes. Medical oversight and quality initiatives focusing on outcomes of patients with timely sensitive emergencies are needed to advance the prehospital care system in Lebanon.

Correction to: Mucormycosis in hospitalized patients at a tertiary care center in Lebanon: a case series.

The spelling of the name "Ali Bazarbachi" was incorrect.

Mucormycosis in hospitalized patients at a tertiary care center in Lebanon: a case series.

Mucormycosis (MCM) is a rare fungal infection affecting people with impaired immunity. Data related to MCM from Lebanon are scarce. The aim of this study is to shed light on the epidemiology, incidence, and outcome of patients with MCM hospitalized at a tertiary care center in Lebanon. We conducted a retrospective chart review between Jan 1, 2008 and Jan 10, 2018. All patients with proven or probable MCM were included. A total of 20 patients were included. Their median age was 49years and the majority were males. Comorbidities included mainly hematologic malignancy and diabetes mellitus. Most common sites of involvement were rhino-orbital and pulmonary, respectively. The number of MCM cases/10.000 hospital admissions increased significantly between 2008 and 2017 (0.47 vs. 1.18; P < 0.05). A liposomal amphotericin B formulation alone or in combination with other antifungals was used as a first line agent in all patients. All-cause mortality was 60%; however, death was attributed to MCM in 20% of cases. The incidence of MCM has significantly increased over the past 10years at our institution, most likely due to the increasing patient population at risk. Understanding the epidemiology of MCM in our setting would help guide antifungal therapy.

The Pediatric Disease Spectrum in an Emergency Department at a Tertiary Care Center in Beirut, Lebanon.

The aim of this study was to identify the most common diagnoses for pediatric emergency department (ED) visits at a tertiary care center in Lebanon. A retrospective chart review of pediatric patients (aged ≤18 years) presenting to the American University of Beirut Medical Center ED during 2010-2011 was completed. The common diagnoses among 5 age groups (<1, 1-4, 5-9, 10-14, and 15-18 years) in 3 categories (all pediatric ED visits, treat and release, admitted visits) were assessed. Diagnoses were classified according to the Clinical Classifications Software. Descriptive statistics and Pearson χ2 test were used. A total of 12,637 pediatric ED visits were included. The majority (90.2%) were among the treat-and-release group. The mean age for all patients was 7.2 years, 57.1% of whom were males. The top 5 most common diagnoses for all ED visits included fever of unknown origin, external injuries, upper respiratory tract infections, open wounds, and abdominal pain. Cardiac conditions were the most common reason for admission in children younger than 1 year, intestinal infection among 1 to 4 years old, pneumonia among 5 to 9 years old, and appendicitis among 10 to 14 and 15 to 18 years. Seasonal analysis showed fever of unknown origin to be the most common diagnosis across all seasons. This study is the first to assess pediatric ED visits in a Lebanese setting. The top most common reason was communicable diseases, with fever of unknown origin being the most common reason for all visits, contrary to North America where injury and poisoning are the most common. Noncommunicable diseases (cardiac, pneumonia, gastroenteritis, and appendicitis) were common reasons for admission in different age groups.

The association between cardiovascular disease gene mutations and recurrent pregnancy loss in the Lebanese population.

Recurrent pregnancy loss (RPL) is a problem affecting up to 5% of women of childbearing age due to many factors. Studies have shown that RPL and cardiovascular disease (CVD) may have shared risk factors. We compared the prevalence of 12 cardiovascular disease related gene mutations in patients with a history of RPL to normal controls in a major tertiary care center in Lebanon. The CVD StripAssay (ViennaLab, Austria) was used to analyze the CVD genes on 70 women with RPL history as part of the initial routine workup for recurrent miscarriage at the American University of Beirut Medical Center. The obtained results were compared with data of controls from the Lebanese population using Fisher's exact test and Chi square analysis. Two genes of the CVD panel demonstrated a strong relationship with RPL, including, MTHFR (C677T homozygosity, A1298C homozygosity, and compound heterozygosity for C677T and A1298C) and Factor II (heterozygosity for G20210A). Moreover, a protective role of positive APO-E3 isoform was observed. This study is the first in the Lebanese population in associating RPL with a large panel of CVD related genes.

Increased blaOXA-23-like prevalence in Acinetobacter baumannii at a tertiary care center in Lebanon (2007-2013).

Acinetobacter baumannii has become one of the most feared organisms in hospital-acquired infections during the past decades. Their multi-drug resistant profiles have rendered many broad-spectrum antibiotics ineffective. The purpose of this retrospective study is to describe and compare molecular characteristics of A. baumannii isolated from patients at a tertiary care center in Lebanon from two outbreaks, the first in 2007-2008 as part of a case-controlled study involving Acinetobacter baumannii cases admitted to the ICU and the second in 2013. A total of 148 A. baumannii clinical isolates were collected from various clinical specimens during 2007-2008 and 2013. All A. baumannii isolates were subjected to PCR amplification of blaOXA-23-like and blaOXA-51-like genes of carbapenem resistance. Random amplification of polymorphic DNA (RAPD) was also performed to assess their genomic relatedness. There was an increase in the prevalence of blaOXA-23-like and blaOXA-51-like between the two time periods; however, only with 22% genomic relatedness between 2007-2008 and 2013 isolates. Taking 80% as margin of compatibility, 31 distinct clusters containing 2 to 11 strains were observed in both time periods. The presence of numerous clusters accompanied by a predominant increase in the prevalence of blaOXA-23-like gene between 2007 and 2013 suggests a horizontal transmission of the gene within various strains of the species, constituting a primary factor in the continued increase of carbapenem resistance over the years. As such, infection control measures ought to be taken with the highest priority and compliance among all involved healthcare workers is of utmost importance.

Emergence of Mycobacterium simiae: A retrospective study from a tertiary care center in Lebanon.

ObjectiveThe objective of this study is to describe the clinical significance of Mycobacterium simiae at a major tertiary care center in Lebanon.MethodsThis is a retrospective study of patients with positive cultures for M. simiae isolated between 2004 and 2016 at the American University of Beirut Medical Center.ResultsThis study included 103 M. simiae isolates recovered from 51 patients. Their mean age was 62.7 years. The majority were males and smokers. Specimens were mostly from respiratory sources (97%). Common comorbidities included chronic lung disease (such as chronic obstructive pulmonary disease), solid tumor, systemic disease, and diabetes mellitus. Productive cough and dyspnea were the most common symptoms. Frequent radiographic findings were infiltrates and nodules on chest X-ray and nodules, infiltrates, and bronchiectasis on chest computed tomography scan. Among 18 tested isolates, 5.8% were resistant to clarithromycin, 11.7% to amikacin, and 70–100% to other antimicrobials. Out of 13 patients receiving early treatment, 5 noted improvement, one had recurrence of symptoms, two received alternative diagnosis, and five died. Two of those deaths were related to M. simiae. Common treatment regimens included clarithromycin in different combinations with trimethoprim-sulfamethoxazole, moxifloxacin, and amikacin. Moreover, clofazimine was used in only two patients whose isolates were resistant to all but one agent. Duration of treatment ranged from 6–24 months.ConclusionIn Lebanon, M. simiae is increasingly encountered with true infection rates of at least 47%. Furthermore, the prevalence of multidrug resistance among the Lebanese M. simiae isolates is very high limiting the treatment options.

Increase of blaOXA-23-like in Acinetobacter baumannii at a tertiary care center in Lebanon between 2007 and 2013.

The multi-drug resistant nature of Acinetobacter baumannii isolates have rendered many broad-spectrum antimicrobial agents ineffective against them. The purpose of this retrospective study is to define and compare the molecular characteristics of A. baumannii isolates from patients at a tertiary care center in Lebanon from two outbreaks, the first in 2007-2008, as part of a case-controlled study involving A. baumannii cases admitted to the ICU, and the second in 2013. A total of 148 A. baumannii clinical isolates were collected from various clinical specimens during 2007-2008 and 2013. All A. baumannii isolates were screened for blaOXA-23-like and blaOXA-51-like genes of carbapenem resistance. Additionally, in an effort to assess the degree of the isolates' genomic relatedness, random amplification of polymorphic DNA (RAPD) was performed. There was an increase in the prevalence of blaOXA-23-like and blaOXA-51-like genes between the two time periods; however, only 22% isolate genomic relatedness was calculated between 2007-2008 and 2013. Taking 80% as a margin of compatibility, 31 distinct clusters containing 2 to 11 strains were observed when both time periods were analyzed. The presence of numerous clusters accompanied by a predominant increase in the prevalence of blaOXA-23-like between 2007 and 2013 suggests a horizontal transmission of the gene within various strains of the species, contributing to the persistent increase in carbapenem resistance over the years. Therefore, infection control measures are required with compliance among all healthcare workers.

Prevalence of carbapenem resistance genes and corresponding MIC90 in Enterobacteriaceae at a tertiary care center in Lebanon.

The aim of this study was to correlate genes involved in carbapenem resistance to MIC levels among clinical ESBL and non-ESBL producing carbapenem resistant Enterobacteriaceae (CRE) isolates of Escherichia coli and Klebsiella pneumoniae. E. coli (n = 76) and K. pneumoniae (n = 54), collected between July 2008 and July 2014, were analyzed. The MICs were determined against ertapenem (ERT), imipenem (IMP) and meropenem (MER). PCR was performed on all 130 isolates to amplify the resistance and outer membrane proteins (OMPs) encoding genes: blaOXA-48, blaNDM-1, blaTEM-1, blaCTX-M-15, ompC and ompF. Sequencing was performed on selected isolates. The prevalence of blaOXA-48, blaNDM-1, blaTEM-1, and/or blaCTX-M-15 among E. coli isolates were 36%, 12%, 20% and 80%, respectively, while among K. pneumoniae they were 37%, 28%, 28% and 72%, respectively. K. pneumoniae isolates positive for any of these genes had an MIC90 > 32μg/mL against ERT, IMP and MER, while in E. coli isolates there was a variation in the MIC90 values. Porin impermeabilities were due to mutations in ompC and ompF genes in E. coli, and loss of ompC and ompF genes in K. pneumoniae, and increased MIC90 values. The presence of more than one carbapenem resistance encoding gene and/or ESBL encoding gene did not have an effect on the MIC90 value in K. pneumoniae isolates, while in E. coli it showed higher MIC90 values.

Disease Free Survival of Well Differentiated Thyroid Cancer: 20 years Experience at a tertiary care center in Lebanon

Background: Thyroid cancer is the most common endocrine malignancy. Although relatively common, to date, there is no study about its prognosis in Lebanon. The objectives of this study were to determine the disease free survival, the recurrence rate and possible predictors of recurrence, as well as the rate of post thyroidectomy complications among patients with differentiated thyroid cancer who received treatment at the American University of Beirut Medical Center.&#x0D; Methods and Findings: retrospective observational study of 480 cases of differentiated thyroid cancer who underwent thyroidectomy between January 1995 and June 2014. The mean age was 42±14 years. 74.4% were females. The mean tumor size was 1.9 cm±1.4. Papillary type was predominant (91%). Males had more extra-glandular extension than females (24.8% versus 10.9% respectively, p=0.001), more lymph node involvement (69.7% versus 52.9% respectively, p=0.017) and more vascular invasion (28.1% versus 14.9%, p=0.007). Around 70% of patients had at least one follow up visit after the surgery; among those, the median follow up duration was 4 years (1month-19years). At last follow-up visit, 78.7% were disease free, 14.9% had residual disease and only 6.3% had recurrent disease. By multivariate analysis, age greater than 45 years was the only independent predictor of persistence or recurrence (p=0.03) whereas both age below 45 years and lack of vascular invasion were significant predictors of disease free survival (p=0.001 and p=0.019 respectively).&#x0D; Conclusion: Differentiated thyroid cancer has an overall good prognosis in this cohort of Lebanese patients. Young age and lack of vascular invasion are the most important predictors of disease free survival.&#x0D; &#x0D; Key words: Differentiated thyroid cancer: disease free survival, prognostic factors, recurrence

Multi-drug resistant Acinetobacter species: a seven-year experience from a tertiary care center in Lebanon

BackgroundAcinetobacter species have become increasingly common in the intensive care units (ICU) over the past two decades, causing serious infections. At the American University of Beirut Medical Center, the incidence of multi-drug resistant Acinetobacter baumannii (MDR-Ab) infections in the ICU increased sharply in 2007 by around 120%, and these infections have continued to cause a serious problem to this day.MethodsWe conducted a seven-year prospective cohort study between 2007 and 2014 in the ICU. Early in the epidemic, a case-control study was performed that included MDR-Ab cases diagnosed between 2007 and 2008 and uninfected controls admitted to the ICU during the same time.ResultsThe total number of patients with MDR-Ab infections diagnosed between 2007 and 2014 was 128. There were also 99 patients with MDR-Ab colonization without evidence of active infection between 2011 and 2014. The incidence of MDR-Ab transmission was 315.4 cases/1000 ICU patient-days. The majority of infections were considered hospital-acquired (84%) and most consisted of respiratory infections (53.1%). The mortality rate of patients with MDR-Ab ranged from 52% to 66%.ConclusionMDR-Ab infections mostly consisted of ventilator-associated pneumonia and were associated with a very high mortality rate. Infection control measures should be reinforced to control the transmission of these organisms in the ICU.

Ahmed glaucoma valve in various etiologies of refractory glaucoma: Surgical outcomes and success factors

To study the epidemiology and mid-term results of the Ahmed glaucoma valve (AGV) in various etiologies of refractory glaucoma in a Lebanese center, and to assess complications and factors that influence the surgical success rate. In this retrospective epidemiological study, we reviewed 108eyes with refractory glaucoma that underwent an AGV implantation in a tertiary care center in Lebanon between January2002 and August2014. Findings including best-corrected visual acuity (BCVA), intra-ocular pressure (IOP), number of antiglaucoma medications, factors influencing the surgical outcome, success rate and complications were also reviewed. The mean duration of follow-up was 29.85±21.45months [range, 3-60months]. As in other Arab countries and compared to the rest of the world, the rate of neovascular glaucoma (NVG) was particularly high, occurring in 63eyes (58.3%), and represented the primary cause of refractory glaucoma. Mean IOP was significantly reduced to 17.97±7.35mmHg at the last follow-up visit (P<0.05). Similarly, a significant decrease was noted in the number of antiglaucoma medications (P<0.05). The surgical success rate, defined as a postoperative IOP<21, was significantly higher (62.0%), in older patients, those with baseline BCVA≤2LogMAR and those with a history of hypertension (P<0.01). Hyphema was the most noted complication. The AGV is a safe and effective procedure for lowering IOP in refractory glaucoma patients, with hyphema being the most frequent complication. Both the presence of hyperstension and initial BCVA≤2LogMAR seem to increase the success rate of the procedure. NVG remains the most common etiology for implantation, probably due to uncontrolled diabetes in the Middle East and North Africa.

Thyroid Fine-Needle Aspiration under Ultrasound Guidance: Experience from an Academic Tertiary Care Center in Lebanon

Thyroid nodules are common. Malignancy was reported in only 5-15% of cases. Fine needle aspiration under US guidance (USG-FNA) proved to be accurate for the detection of thyroid cancer. This is a retrospective review of 400 radiology and cytology USG-FNA reports, randomly selected among those done at the Radiology Department at a tertiary care center in Beirut during the last five years. The specimen was inadequate in 60 (12%) of cases but FNA was repeated in 10 cases only. The final diagnosis was benign in 76.7% of cases, mostly in women. 35% of the malignant and 19% of the benign nodules were hypoechoic, p=0.03. No significant correlation was observed between malignancy and other ultrasonic characteristics. Hypoechogenecity was also more common in nodules with inadequate specimen (40% versus 21.4%, p=0.01). Age, gender, location and size of the nodule did not differ between groups of adequate and inadequate specimen. In conclusion, 3 out of 4 thyroid nodules referred for USG-FNA are benign, mostly in women. Inadequate specimen was observed in 12% of cases. Hypoechogenecity but not other ultrasonic characteristics was associated with malignancy and with test failure.&#x0D; &#x0D; Key words: Thyroid nodule, fine needle aspirate, ultrasound guidance, thyroid cancer, inadequate.

Five-Year Incidence and Progression of Diabetic Retinopathy in Patients with Type II Diabetes in a Tertiary Care Center in Lebanon.

Objective To estimate the 5-year incidence of progression rate and regression rate and risk factors for diabetic retinopathy (DR) in a cohort of Lebanese patients with type II diabetes. Methods We followed a cohort of 462 Lebanese patients with type II diabetes for over 5 years at the American University of Beirut Medical Center. Patients underwent yearly complete ophthalmic evaluation and fundus photographs and were assessed for the incidence, stage, and evolution of DR using modified Airlie House classification. Results Among the 462 patients, 281 had no DR at baseline. The 5-year cumulative incidence of any DR was 10% (95% CI: 6–13), and only baseline microalbuminuria correlated with the development of DR (OR = 10.53, 95% CI: 4.39–25.23, p < 0.0001). Among the 181 patients with baseline DR, the worsening and regression rates of DR were 31.5% (95% CI: 25–38) and 9% (95% CI: 5–13), respectively. Microalbuminuria also approached statistical significance as a risk factor for DR worsening (OR = 1.89, 95% CI: 0.97–3.70, p = 0.06). Conclusion The 5-year incidence of DR in this hospital-based cohort is relatively low. Microalbuminuria was independently associated with the incidence and progression of the disease. We recommend to screen patients with type II diabetes for microalbuminuria as prognostic for the development and worsening of DR.

Are patients with cancer with sepsis and bacteraemia at a higher risk of mortality? A retrospective chart review of patients presenting to a tertiary care centre in Lebanon

ObjectiveMost sepsis studies have looked at the general population. The aim of this study is to report on the characteristics, treatment and hospital mortality of patients with cancer diagnosed with...

Older Adults Had Similar Survival Rates Compared to Their Younger Counterparts Following Cardiopulmonary Resuscitation

Background: Several factors affect the outcome of cardiopulmonary resuscitation (CPR) following in hospital cardiac arrests, including presence of comorbidities, arrest characteristics, and resuscitation efforts. We sought to determine the outcome of CPR provided to elders suffering from in-hospital cardiopulmonary arrest and to compare it to the survival of their younger counterparts in a tertiary care center in Lebanon. Methods: Retrospective chart review of all patients suffering from cardiac arrests who received CPR during a one year period in a tertiary care center located in a rural area. Results: A total of 98 cardiac arrests were identified who received CPR according to advance cardiac life support protocols (ACLS). Initial return of spontaneous circulation was higher among younger subjects but the difference was not statistically significant (52.6% vs 34.2%, p = 0.136). Survival to discharge was low but slightly higher in the younger subgroup, yet the difference was not statistically significant (5% vs 3%, p = 0.535). Conclusions: Physicians need to be aware of the outcome of CPR in the hospitals they practice in. They can educate their patients about CPR outcome. Such education may help patients and their next of kin make informed decisions jointly with their physician regarding resuscitation.

Genotype distribution of hepatitis C virus among Lebanese patients: Results from a major tertiary care center

AimsThe determination of hepatitis C virus (HCV) genotype is a crucial element in the therapeutic management of HCV infected patients. Studies showed that different treatment responses were obtained for different genotypes. The aim of this research study is to assess the distribution of hepatitis C virus genotypes in chronic HCV patients from a major tertiary care center in Lebanon. Materials and methodsFor all HCV patients referred for viral load testing at the American University of Beirut Medical Center, we reviewed the HCV genotyping results for 203 patients positive for HCV RNA using the Linear Array Genotyping kit. ResultsHCV genotypes were distributed as follows: Genotype 1 (39.6 42.86%), Genotype 3 (27.6 26.11%), Genotype 4 (26.0 24.63%), Genotype 2 (3.6 3.45%), and Genotype 5 (3.1 2.96%). Genotype 6 was not detected in any case from our patient population. ConclusionUnlike previous studies in the country, our study interestingly showed a shift in viral genotype from Genotype 4 as the most predominant few years back to a current Genotype 1 predominance. Future epidemiological investigations, especially in light of these interesting results which differ from other populations in the Middle East region and show HCV viral profile changes, are warranted.

Candida profiles and antifungal resistance evolution over a decade in Lebanon.

Infection with and antifungal resistance of Candida species have been on the rise globally. Relevant data on these pathogens are relatively few in our region, including Lebanon, thus warranting this study. This retrospective study of Candida spp. profiles and their in vitro antifungal susceptibility was based on analysis requests for 186 Candida non-albicans and 61 C. albicans during three periods (2005-2007, 2009-2011, and 2012-2014) over the span of the last 10 years at the American University of Beirut Medical Center (AUBMC), a major tertiary care center in Lebanon. Identification of Candida was done using the API 20C AUX system, and the E-test was used to determine the minimum inhibitory concentrations (MICs) of antifungal agents. Among the 1,300-1,500 Candida isolates recovered yearly, C. albicans rates decreased from 86% in 2005 to around 60% in 2014. Simultaneously, the non-albicans rates increased from 14% in 2005 to around 40% in 2014, revealing 11 species, the most frequent of which were C. tropicalis, C. glabrata, and C. parapsilosis. All these demonstrated high resistance (35%-79%) against itraconazole, but remained uniformly susceptible (100%) to amphotericin B. Though C. albicans and the other species maintained high susceptibility against fluconazole and voriconazole, their MIC90 showed an elevated trend over time, and C. glabrata had the highest resistance rates. The observed rise in resistance among Candida spp. in Lebanon mandates the need for close surveillance and monitoring of antifungal drug resistance for both epidemiologic and treatment purposes.

Prevalence of Clostridium difficile toxinotypes in infected patients at a tertiary care center in Lebanon.

Due to the increase in the incidence of Clostridium difficile associated diseases at a tertiary care center in Lebanon, this study was undertaken to determine the prevalent C. difficile toxinotypes. The immunocard method was used to test for toxins A and B in 88 collected stool samples, followed with API 20A to confirm for C. difficile. PCR amplification of the triose phosphate isomerase (tpi) gene, the toxin encoding genes tcdA, and tcdB, followed by toxinotyping, were performed on recovered isolates and stool specimens. Out of the 88 stool samples obtained, 30 (65.2%) were Immunocard positive, culture and or tpi positive for C. difficile. Of the 30 isolates, 4 were PCR negative for the tcdA and tcdB genes (A-B-), and 26 were PCR positive for the tcdA and / or tcdB genes with 4 being A+B+, 1 A+B-, and 21 A-B+. The results of toxinotyping showed that 2 isolates belonged to toxinotype 0, 4 to toxinotype XI, 2 to toxinotype XII, 1 to toxinotype XVI, 1(A+B-) and twenty (A-B+) designated as toxinotype 0-like. C. difficile was detected in 65.2% of patients' stools with prevalence of toxinotype 0-like. Identification of toxinotypes of C. difficile is important to determine the virulence potential of strains and control their spread.