The effect of home-based care on housebound patients and their caregivers in two Palestinian refugee camps in Lebanon: a qualitative study.

BACKGROUND: The incidence of non-communicable diseases (NCDs) increases annually by approximately 5% among older (age 50 years and older) Palestinian refugees in Lebanon, of whom around 10% are housebound. Care for housebound patients does not exist in the over-medicalised and highly privatised Lebanese health system or within the health system for Palestinian refugees in Lebanon. This has led to a neglected population. In 2016, Médecins Sans Frontières (MSF) started to provide home-based care (HBC) for housebound patients in two Palestinian camps: Bourj-el-Barajneh and Ain-al-Hilweh. HBC is carried out by a team comprising a doctor, nurse, and social worker, and includes basic medical monitoring, health literacy educational sessions, support for treatment adherence, as well as networking with relevant social service providers. METHODS: A qualitative study was carried out between January and October, 2018, nine patients, ten caregivers, and personnel from two main international non-governmental organisations providing health care for refugees were interviewed, and one focus group discussion was conducted with MSF HBC staff. Thematic content analysis was carried out manually, with investigators' observations for triangulation. The study was approved by the MSF ethical review board. FINDINGS: The housebound patients described various ways in which they felt socially isolated, useless, and unproductive. These are underserved needs. Caregivers reported feeling burdened socially, mentally, and financially. They also reported that they assumed full responsibility for the housebound relative, as there was no alternative. HBC was appreciated by patients and caregivers for providing psychosocial and medical support; patients viewed MSF staff as a "friend in care", a temporary escape from isolation, and caregivers expressed appreciation for sharing the burden of caring for the housebound person. There was a decrease in anxiety expressed by caregivers and patients, as well as a declining sense of burden described by caregivers, during the provision of HBC by the MSF staff. To a lesser extent, patients and caregivers sensed improved self management as their disease literacy and treatment adherence increased, and as caregivers became more efficient in handling toilet care, bathing, and wound dressing. Missing components of HBC were perceived to be "outdoor" activities and mental health services. INTERPRETATION: HBC had an effect in reducing patients' social isolation, decreasing caregivers' burden and anxiety, and enhancing self management of disease for both. HBC should be considered for replication by all refugee health care providers as well as by the Lebanese Ministry of Public Health. This model of care needs to adopt a more holistic approach by including provision of mental health care and by increasing the focus on social isolation. FUNDING: None.

Self-reported medication adherence among patients with diabetes or hypertension, Médecins Sans Frontières Shatila refugee camp, Beirut, Lebanon: A mixed-methods study.

INTRODUCTION: Low adherence to medications, specifically in patients with Diabetes (DM) and Hypertension (HTN), and more so in refugee settings, remains a major challenge to achieving optimum clinical control in these patients. We aimed at determining the self-reported medication adherence prevalence and its predictors and exploring reasons for low adherence among these patients. METHODS: A mixed-methods study was conducted at Médecins Sans Frontières non-communicable diseases primary care center in the Shatila refugee camp in Beirut, Lebanon in October 2018. Data were collected using the validated Arabic version of the 8-items Morisky Medication Adherence Scale (MMAS-8) concurrently followed by in-depth interviews to explore barriers to adherence in patients with DM and/or HTN. Predictors of adherence were separately assessed using logistic regression with SPSS© version 20. Manual thematic content analysis was used to analyze the qualitative data. RESULTS: Of the 361 patients included completing the MMAS, 70% (n = 251) were moderately to highly adherent (MMAS-8 score = 6 to 8), while 30% (n = 110) were low-adherent (MMAS-8 score<6). Patients with DM-1 were the most likely to be moderately to highly adherent (85%; n = 29). Logistic regression analysis showed that patients with a lower HbA1C were 75% more likely to be moderately to highly adherent [(OR = 0.75 (95%CI 0.63-0.89), p-value 0.001]. Factors influencing self-reported moderate and high adherence were related to the burden of the disease and its treatment, specifically insulin, the self-perception of the disease outcomes and the level of patient's knowledge about the disease and other factors like supportive family and healthcare team. CONCLUSION: Adherence to DM and HTN was good, likely due to a patient-centered approach along with educational interventions. Future studies identifying additional factors and means addressing the barriers to adherence specific to the refugee population are needed to allow reaching optimal levels of adherence and design well-informed intervention programs.

First cases of Burkholderia cenocepacia IIIA neonatal sepsis in Central African Republic.

Bacteria of the Burkholderia cepacia complex cause frequent infections in immunocompromised and hospitalized patients, with a significant mortality rate. Phenotypic identification of those bacteria is difficult and therefore rarely reported from developing countries. This study presents the first ever reported case series of Burkholderia cenocepacia neonatal sepsis in Central African Republic. It demonstrates the superiority of molecular methods to accurately identify B. cenocepacia IIIA species compared to the phenotypic methods.

Pediatric appendectomy in developing countries: How does it differ from international experience?

INTRODUCTION: A review of the English literature indicates the faint superiority of laparoscopic (LA) over open appendectomy (OA) in the pediatric population; however, a developing-country's experience in the field is not available yet. This study presents our experience in LA versus OA over the last 7 years in one university hospital in Lebanon and compares our results to the international ones. METHOD: A single center retrospective study was done including all patients aged less than 15 years who underwent appendectomy. A description of each operative technique is presented. Patients' characteristics, intraoperative finding, operative timing (OT), length of stay (LOS) and short term postoperative complications including surgical site infection (SSI) rate, intra-abdominal abscess formation (IAA) rate and reoperation rate were all studied. Statistical analysis was done using Chi-square or Fisher's exact test, as for continuous, Student's t test was used or one-way ANOVA in case of more than 2 categories. RESULT: Appendectomy was performed in 84 patients. 52 patients underwent OA through a Rocky Davis incision, and 32 patients underwent a LA. We found an advantage of LA over OA in reducing SSI, otherwise both approaches were similar. CONCLUSION: In accordance with international results, in our experience, LA is superior to OA only with regards to SSI.

Treating Syrian refugees with diabetes and hypertension in Shatila refugee camp, Lebanon: Médecins Sans Frontières model of care and treatment outcomes.

BACKGROUND: Médecins Sans Frontières (MSF) has been providing primary care for non-communicable diseases (NCDs), which have been increasing in low to middle-income countries, in the Shatila refugee camp, Beirut, Lebanon, using a comprehensive model of care to respond to the unmet needs of Syrian refugees. The objectives of this study were to: 1) describe the model of care used and the Syrian refugee population affected by diabetes mellitus (DM) and/or hypertension (HTN) who had ≥ one visit in the MSF NCD clinic in Shatila in 2017, and 2) assess 6 month treatment outcomes. METHODS: A descriptive retrospective cohort study using routinely collected program data for a model of care for patients with DM and HTN consisting of four main components: case management, patient support and education counseling, integrated mental health, and health promotion. RESULTS: Of 2644 Syrian patients with DM and/or HTN, 8% had Type-1 DM, 30% had Type-2 DM, 30% had HTN and 33% had DM + HTN. At intake, patients had a median age of 53, were predominantly females (63%), mostly from outside the catchment area (70%) and diagnosed (97%) prior to enrollment. After 6 months of care compared to intake: 61% of all patients had controlled DM (HbA1C < 8%) and 50% had controlled blood pressure (BP: < 140/90 mmHg) compared to 29 and 32%, respectively (p < 0.001). Compared to intake, patients with Type-1 DM reached an HbA1C mean of 8.4% versus 9.3% (p = 0.022); Type-2 DM patients had an HbA1C mean of 8.1% versus 9.4% (p = 0.001); and those with DM + HTN reached a mean HbA1C of 7.7% versus 9.0%, (p = 0.003). Reflecting improved control, HTN patients requiring ≥3 medications increased from 23 to 38% (p < 0.001), while DM patients requiring insulin increased from 21 to 29% (p < 0.001). Loss-to-follow-up was 16%. CONCLUSIONS: The MSF model of care for DM and HTN operating in the Shatila refugee camp is feasible, and showed promising outcomes among enrolled individuals. It may be replicated in similar contexts to respond to the increasing burden of NCDs among refugees in the Middle-East and elsewhere.

Risk Factors, Clinical Presentation, and Outcome of Acinetobacter baumannii Bacteremia.

Infections caused by Acinetobacter baumannii (AB), an increasingly prevalent nosocomial pathogen, have been associated with high morbidity and mortality. We conducted this study to analyze the clinical features, outcomes, and factors influencing the survival of patients with AB bacteremia. We retrospectively examined the medical records of all patients developing AB bacteremia during their hospital stay at a tertiary care hospital in Beirut between 2010 and 2015. Ninety episodes of AB bacteremia were documented in eighty-five patients. Univariate analysis showed that prior exposure to high dose steroids, diabetes mellitus, mechanical ventilation, prior use of colistin and tigecycline, presence of septic shock, and critical care unit stay were associated with a poor outcome. High dose steroids and presence of septic shock were significant on multivariate analysis. Crude mortality rate was 63.5%. 70.3% of the deaths were attributed to the bacteremia. On acquisition, 39 patients had septicemia. Despite high index of suspicion and initiation of colistin and/or tigecycline in 18/39 patients, a grim outcome could not be averted and 37 patients died within 2.16 days. Seven patients had transient benign bacteremia; three of which were treated with removal of the line. The remaining four did not receive any antibiotics due to withdrawal of care and died within 26.25 days of acquiring the bacteremia, with no signs of persistent infection on follow up. A prolonged hospital stay is frequently associated with loss of functionality, and steroid and antibiotic exposure. These factors seem to impact the mortality of AB bacteremia, a disease with high mortality rate and limited therapeutic options.

A methodological survey identified eight proposed frameworks for the adaptation of health related guidelines.

BACKGROUND AND OBJECTIVE: Our objective was to identify and describe published frameworks for adaptation of clinical, public health, and health services guidelines. METHODS: We included reports describing methods of adaptation of guidelines in sufficient detail to allow its reproducibility. We searched Medline and EMBASE databases. We also searched personal files, as well manuals and handbooks of organizations and professional societies that proposed methods of adaptation and adoption of guidelines. We followed standard systematic review methodology. RESULTS: Our search captured 12,021 citations, out of which we identified eight proposed methods of guidelines adaptation: ADAPTE, Adapted ADAPTE, Alberta Ambassador Program adaptation phase, GRADE-ADOLOPMENT, MAGIC, RAPADAPTE, Royal College of Nursing (RCN), and Systematic Guideline Review (SGR). The ADAPTE framework consists of a 24-step process to adapt guidelines to a local context taking into consideration the needs, priorities, legislation, policies, and resources. The Alexandria Center for Evidence-Based Clinical Practice Guidelines updated one of ADAPTE's tools, modified three tools, and added three new ones. In addition, they proposed optionally using three other tools. The Alberta Ambassador Program adaptation phase consists of 11 steps and focused on adapting good-quality guidelines for nonspecific low back pain into local context. GRADE-ADOLOPMENT is an eight-step process based on the GRADE Working Group's Evidence to Decision frameworks and applied in 22 guidelines in the context of national guideline development program. The MAGIC research program developed a five-step adaptation process, informed by ADAPTE and the GRADE approach in the context of adapting thrombosis guidelines. The RAPADAPTE framework consists of 12 steps based on ADAPTE and using synthesized evidence databases, retrospectively derived from the experience of producing a high-quality guideline for the treatment of breast cancer with limited resources in Costa Rica. The RCN outlines five key steps strategy for adaptation of guidelines to the local context. The SGR method consists of nine steps and takes into consideration both methodological gaps and context-specific normative issues in source guidelines. We identified through searching personal files two abandoned methods. CONCLUSION: We identified and described eight proposed frameworks for the adaptation of health-related guidelines. There is a need to evaluate these different frameworks to assess rigor, efficiency, and transparency of their proposed processes.

Methods used in adaptation of health-related guidelines: A systematic survey.

BACKGROUND: Adaptation refers to the systematic approach for considering the endorsement or modification of recommendations produced in one setting for application in another as an alternative to de novo development. OBJECTIVE: To describe and assess the methods used for adapting health-related guidelines published in peer-reviewed journals, and to assess the quality of the resulting adapted guidelines. METHODS: We searched Medline and Embase up to June 2015. We assessed the method of adaptation, and the quality of included guidelines. RESULTS: Seventy-two papers were eligible. Most adapted guidelines and their source guidelines were published by professional societies (71% and 68% respectively), and in high-income countries (83% and 85% respectively). Of the 57 adapted guidelines that reported any detail about adaptation method, 34 (60%) did not use a published adaptation method. The number (and percentage) of adapted guidelines fulfilling each of the ADAPTE steps ranged between 2 (4%) and 57 (100%). The quality of adapted guidelines was highest for the "scope and purpose" domain and lowest for the "editorial independence" domain (respective mean percentages of the maximum possible scores were 93% and 43%). The mean score for "rigor of development" was 57%. CONCLUSION: Most adapted guidelines published in peer-reviewed journals do not report using a published adaptation method, and their adaptation quality was variable.