Hospitals' Collaborations Strengthen Pandemic Preparedness: Lessons Learnt from COVID-19.

BACKGROUND: The COVID-19 pandemic strained healthcare systems around the world. This study aims to understand the preparedness of private remote hospitals in Lebanon to respond to the pandemic and evaluate the impact of inter-hospital collaborations on the hospitals' readiness. METHODS: A multi-centered study was conducted between August 2020 and June 2021 in ten Lebanese private remote hospitals based on a mixed-methods embedded approach where the quantitative supported the qualitative. Through the AUB-USAID (American University of Beirut-United States Agency for International Development) COVID-19 project, these hospitals received personal protective equipment and medical equipment in addition to COVID-19-related training using the Train-the-Trainer model. The quantitative part used knowledge and evaluation questionnaires and a pre-post-intervention hospital preparedness checklist. The qualitative approach adopted semi-structured interviews with a purposive sample from key hospital personnel. Quantitative data were analyzed using SPSS version 27, and a p-value of <0.05 was considered to be statistically significant. For the qualitative data, a thematic analysis was performed by adopting the six-phase process described by Braun and Clarke. RESULTS: Of the 393 healthcare workers who attended the training and completed the evaluation questionnaire, 326 completed the pre- and post-training knowledge questionnaire. A significant improvement was observed in mean knowledge scores following training for infection control, nursing, and polymerase chain reaction sampling staff (p-value < 0.001, p-value < 0.001, and p-value = 0.006, respectively), but not for housekeeping staff. More than 93% of the participants showed high trainer and content evaluation scores. As for the hospitals' preparedness assessments, there was a clear improvement in the pre- and post-assessment scores for each hospital, and there was a significant difference in the mean of the total scores of partner hospitals pre- and post-USAID-AUB project (p-value = 0.005). These findings were supported by the qualitative analysis, where nine hospitals expressed the positive impact of the USAID-AUB intervention in improving their preparedness to respond to the COVID-19 pandemic at a critical time when it was highly needed. Despite the intervention, persistent challenges remained. CONCLUSIONS: A timely and proactive collaborative program between academic/tertiary care centers and remote community hospitals that includes sharing supplies and expertise is feasible and highly effective during public health emergencies.

Advanced Practice Providers in Departments of Family Medicine: Status, Supervision, and Services.

BACKGROUND: Nurse practitioners (NP), physician assistants (PA), and other advanced practice providers (APP) are one solution to meet health care workforce shortage. Our study examined clinical workforce decisions and perceptions of APPs and family physicians (FPs) from the perspective of a national survey chairs of Departments of Family Medicine. METHODS: A survey was developed and distributed to family medicine department chairs as identified by the Association of Departments of Family Medicine (ADFM). In addition to demographic information, respondents were asked if their department directly employs APPs, major factors influencing departments of family medicine to hire APPs, services to patients currently being provided by APPs, and services preferentially provided by APPs. Descriptive statistics were reviewed. Bivariate analyses and Chi-square were computed comparing perceptions of APPs and FPs by how these types of health care providers are currently used in the respondent's clinical operation. RESULTS: The overall response rate for the survey was 48.4% (109/225). Most departments of family medicine (62.4%) use APPs. Access to care and filing gaps in team-based care are the primary factors for APP employment. Although most departments have APPs provide services that include complex chronic conditions complicated by coexisting conditions or not yet controlled, most department chairs do not prefer APPs provide these services. DISCUSSION: The role APPs in terms of specific patient care activities and services in the health care team of departments of family medicine is often in conflict with preferred roles as delineated by the chair.

Effectiveness of a modified Balint group process on empathy and psychological skills employing Kirkpatrick's evaluation framework.

Background: To evaluate, using Kirkpatrick's evaluation model, a modified Balint group (BG) by adding 5-10 min at the end of the session, where the facilitators will debrief the residents about critical themes mentioned in the session. Methods: A quasi-experimental study with a mixed-method design was conducted among family medicine residents over 1 year, using focus groups and validated tools filled by residents and their corresponding patients. The residents' empathy through self and patient evaluation, psychological skills, and satisfaction with the educational activity were measured. Results: The focus group revealed that the residents were aware of the change and considered it a closure to the encounter, helping decrease some uncertainty. Most of the residents did not consider the change helpful. Using validated instruments, BG was ineffective at improving the residents' empathy and psychological skills. There was a statistically significant main effect of time on Psychological Medicine Inventory (PMI) scores, F (1,13) = 7.709, p = 0.016. Conclusion: Debriefing at the end of BG by the facilitators about key themes may help give the residents closure, decrease the uncertainty, and make them more aware of their feelings. Nevertheless, Balint groups are still not very well accepted by the residents, and they prefer direct feedback and support groups.

Psychosocial wellbeing and risky health behaviors among Syrian adolescent refugees in South Beirut: a study using the HEEADSSS interviewing framework.

Purpose: Adolescent refugees are at risk of mental health disorders and underdiagnosed risky behaviors. Limited research exists in the Middle East and North Africa. This study aims to assess psychosocial wellbeing and risk-taking behaviors among adolescent refugees displaced to South Beirut following a standardized framework. Methods: A cross-sectional study using face-to-face confidential HEEADSSS (Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Safety and Suicide/Depression) interviews was conducted among 52 Syrian adolescent refugees, between the ages of 14 and 21, in a health center in South Beirut. Results: The mean age of the interviewees was 17.04 ± 1.77 years, with a male predominance 34 (65.4%). Five (9.6%) were married, 38 (73.1%) were not attending school 27 (52.9%) lived in a place with a crowding index ≥3.5 and 21 (40.4%) were working. Risky health concerns or behaviors detected included no activities or exercise 38 (73.1%), eating one to two meals per day 39 (75%) and smoking 22 (42.3%). Eleven (21.2%) have been ever offered drugs and 22 (42.3%) believed they should carry a weapon for protection. Twenty one out of 32 (65.7%) had major depressive disorders and 33 (63.5%) screened positive for behavioral problems. Exposure to home verbal or physical violence, male gender, smoking, and employment were associated with high scoring in behavioral problems. Smoking and ever been touched in an unwanted way were found to be associated with depression. Conclusion and practical implications: Implementing the HEEADSSS interviewing assessment within medical encounters with refugee adolescents is one efficient way to detect risky health behaviors and mental health problems. Interventions need to be implemented as early as possible in the refugees' journey to help them cope and gain resilience. Training health care providers to conduct the questionnaire and delivering brief counseling when required is recommended. Establishing a network of referrals to provide multidisciplinary care to adolescents can be helpful. Obtaining a fund to distribute safety helmets for adolescent motorbike drivers can be a way to reduce injuries. More research among adolescent refugees in multiple settings, including teenagers in the host country, is needed to serve this population better.

Comparative effectiveness of mobile health smoking cessation approaches among underserved patients in primary care: Study protocol for the PROMOTE-UP trial.

INTRODUCTION: Tobacco smoking is the leading cause of preventable disease, disability, and premature death in the United States. Recent advances have led to two efficacious mobile health (mHealth) treatments for smoking cessation: iCanQuit, an Acceptance and Commitment Therapy-based behavioral treatment promoting cessation through accepting triggers and committing to values; and Motiv8, a contingency management intervention promoting smoking cessation with financial incentives via biochemically verified abstinence. This study will evaluate the comparative effectiveness of the Florida Quitline, iCanQuit alone, and iCanQuit+Motiv8 in a pragmatic trial among patients who smoke in underserved primary care settings. METHODS: The study will be an individually-randomized controlled trial with three arms (Florida Quitline, iCanQuit alone, iCanQuit+Motiv8 combined) conducted in multiple primary care practices affiliated with the OneFlorida+ Clinical Research Consortium. Adult patients who smoke will be randomized to one of the 3 study arms (n = 444/arm), stratified by healthcare setting (academic vs. community). The primary outcome will be 7-day point prevalence smoking abstinence at 6 months post-randomization. Secondary outcomes will be 12-month smoking abstinence, patient satisfaction with the interventions, and changes in patient quality of life and self-efficacy. The study will also assess how and for whom the interventions help sub-group patients in achieving smoking abstinence by measuring theory-derived factors that mediate smoking outcome-specific baseline moderators. CONCLUSIONS: Results from this study will provide evidence for the comparative effectiveness of mHealth smoking cessation interventions in healthcare settings. Use of mHealth interventions can make smoking cessation resources more equitably accessible and have far-reaching impact on community and population health. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05415761, Registered 13 June 2022.

Prevalence of STIs, sexual practices and substance use among 2083 sexually active unmarried women in Lebanon.

Access to sexual and reproductive health in conservative communities and in the MENA region are particularly limited and, as such, increase women's vulnerability to unwanted pregnancies, unsafe abortions, and sexually transmitted infections (STIs). The aim was to assess the prevalence of STIs, sexual practices, recreational drug-use and their possible associations among cisgender unmarried women residing in Lebanon. Data on demographics, sexual practices and substance-use were collected from 2083 unmarried cisgender women who voluntarily attended a sexual health clinic in Lebanon between 2015 and 2019. They tested for HIV, Hepatitis B, Hepatitis C and Syphilis through rapid testing. Other infections (genital warts, Neisseria gonorrhea/Chlamydia trachomatis) were screened for. Regression models were computed between variables. There were two cases of HIV, one of Hepatitis B and syphilis, and no cases of Hepatitis C. Genital warts were present in 15% and symptoms indicative of Neisseria gonorrhea/Chlamydia trachomatis in 14%. Inconsistent condom-use (81%) was significantly associated with number of partners (adj. OR: 0.4). Inconsistent condom-use discussion with partners (33%) was significantly associated with unemployment (adj OR: 1.7), recreational drug-use (adj. OR: 1.4), and number of partners (adj. ORs 3.7-4.4). Unwanted pregnancies (11%) were significantly associated with age (adj. ORs 0.1-0.37), recreational drug-use (adj. OR: 2), using intrauterine device (adj. OR:2.9) and natural birth control methods (adj. OR: 2.4). Recreational drug-use (33%) was significantly associated with age (adj ORs 1.9-2.2), and smoking status (adj. OR: 0.6). The results indicate an urgent need for: (1) Accessible, non-stigmatizing, and inclusive sexual health services dedicated to women's sexual health; (2) Comprehensive and non-stigmatizing sexual health education for all, but especially women, in order to promote safer sexual practices and effective decision making with regards to contraception and condom-use.

Impact of Sleep on Medical Residents' Emotions: A Cross-Sectional Study Using a Wearable Device.

BACKGROUND AND OBJECTIVES: Controlling negative emotions and getting sufficient sleep are key factors in reducing medical errors and optimizing quality of care. The objective of this study was to measure the relationship between the emotions of medical residents and sleep as measured by a wearable device. METHODS: We conducted a cross-sectional study addressing all residents of all postgraduation years and specialties at an Accreditation for Graduate Medical Educations-I accredited institution over 6 months. Sleep quantity and quality were measured by Fitbit Charge 2 device, and daily emotions by the Positive and Negative Affect Schedule questionnaire. RESULTS: We included a total of 45 participants with a total of 1,112 observations (response rate=19.3%). The mean duration of total daily sleep was 5.9±1.6 hours, with a deep sleep time of 1.1±0.4 hours. We found a negative association between negative emotions and total sleep (rrm=-0.14, P<.0001) and deep sleep (rrm=-0.11, P=.0005) using repetitive measures correlation. A linear regression model to predict the negative emotions of the residents revealed additional determinants beyond deep sleep. CONCLUSIONS: Our findings provide a further understanding of the importance of sleep quality on emotions by emphasizing deep sleep as a predictor of the second-day affect. Residency programs should strive to provide an ideal sleep environment to their residents and deliver workshops to deal with negative emotions.

Prevalence of HIV and other sexually transmitted infections and their association with sexual practices and substance use among 2238 MSM in Lebanon.

UNAIDS report documents 95% increase in new HIV infections among key populations in Eastern Europe and Middle East and North Africa region. Data on HIV and STIs among MSM in Lebanon is still scarce. Therefore, the aim was to assess prevalence of HIV and sexually transmitted infections (STIs) among men who have sex with men (MSM) in Lebanon and associations with sexual practices and substance-use. 2238 MSM attended a sexual health clinic in Lebanon between 2015-2018. Demographics, substance-use and sexual practices were collected. Attendees tested for HIV and other STIs. HIV infection was diagnosed in 5.6% of the sample. Only 19% received sexual health education from reliable sources (school/university/healthcare workers), 78% reported having multiple partners in the past three months (2-5 partners: 58%, 6+: 20%) and 67% reported inconsistent condom-use. Moreover, 40% of HIV + cases were returning attendees who already received information about condom-use. Additionally, having only a school level education (11%) increases the odds of having inconsistent condom-use with casual partners (adj.OR:1.9, p < 0.001). The results reflect the urgent need for: (1) accurate and comprehensive sexual health and harm reduction education and promotion in Lebanon; (2) making pre-exposure prophylaxis available for free to key populations to contain the epidemics at an early stage.

Oesophageal ulcer due to a herbal remedy.

Herbal-induced oesophageal lesions are rare. We report the case of an 85-year-old male who presented with cough and odynophagia. An upper endoscopy showed white deposit under the proximal oesophageal sphincter. Biopsy of the lesion revealed an oesophageal ulcer with adherent plant material and ruled-out candidiasis. At this point, the patient divulged self-preparation of an herbal remedy consisting of Aloe Vera pulp, whisky, honey, ginger and turmeric. Aloe Vera, ginger and turmeric are commonly used to sooth some gastroenterological symptoms in Complementary and Alternative Medicine. Incorrect extraction of Aloe Vera pulp and adding honey to it transformed the recipe into a sticky paste that may have injured the oesophageal mucosa. Follow-up showed that the cough and odynophagia subsided after discontinuing this herbal remedy.

A Vulvovaginal Mass in a 16-Year-Old Adolescent: A Case Report.

BACKGROUND: Vulvar varicosities might be misdiagnosed as vulvar venous malformations in the prepubertal or pubertal age. If seen isolated, they can mimic other masses that are usually seen in this anatomic area like a hernia or a cyst. Depending on the associated symptoms and clinical findings, imaging modalities investigate the nature of such a mass and might provide a therapeutic alternative besides surgery. CASE: We report a case of an isolated asymptomatic vulvar varicosity in a 16-year-old adolescent. A pelvic ultrasound followed by a Doppler and a magnetic resonance imaging scan confirmed the diagnosis. We used guided direct sclerotherapy for successful treatment. SUMMARY AND CONCLUSION: Optimal management and outcome are assured using a multidisciplinary approach. Guided sclerotherapy provides a safe, effective, and minimally invasive procedure to treat vulvar varicosities.