QTc prolongation during levofloxacin and triazole combination chemoprophylaxis: Prevalence and predisposing risk factors in a cohort of hematopoietic cell transplantation recipients.

BACKGROUND: QTc interval prolongation has been reported when combining fluoroquinolones and triazoles for chemoprophylaxis in cancer patients. Herein, we aimed to identify the prevalence and contributing factors to QTc prolongation in hematopoietic cell transplantation (HCT) recipients who received these agents during the neutropenic phase. METHODS: This is a retrospective medical chart review conducted at a university hospital in Lebanon from 2017 to 2020. It included all adult HCT inpatients on antimicrobial prophylaxis with fluoroquinolones and triazoles and whose baseline ECG monitoring done prior to chemoprophylaxis administration, then on day-3 and day-6 of therapy, were available. RESULTS: Overall, 68 HCT recipients met our inclusion criteria, of which 22% developed QTc prolongation. Based on bivariate analysis, female gender contributed to QTc prolongation (P = 0.001). There was a trend to QTc prolongation in patients with predisposing thyroid disease (P = 0.12), grade 2 vomiting and diarrhea (P = 0.16, P = 0.46, respectively), baseline hypokalemia (P = 0.18) and hypocalcemia (P = 0.3), hypomagnesemia on day-3 (P = 0.21) and day-6 hyponatremia (P = 0.36). Patients receiving two or more drugs with a known or probable risk of QTc prolongation (other than the fluoroquinolone/ triazole combination) were more prone to experience a prolonged QTc interval (P = 0.09). None of the patients that had QTc prolongation died or developed serious arrhythmias. CONCLUSION: The prevalence of QTc prolongation was 22% among HCT recipients on fluoroquinolone and triazole prophylaxis, yet we did not identify any independent risk factors for this issue. None of the patients that had QTc interval prolongation died or developed serious arrhythmias.

Distribution of international medical graduates across USA surgical training programs: a descriptive cross-sectional study.

BACKGROUND: International medical graduates (IMGs) have been a critical part of the USA healthcare in the past 30 years, especially in small rural and poor counties. However, little to no publications are present on the distribution of these IMGs across general surgery residency programs. METHODS: All freely accessible information on current residents in accredited general surgery residency programs within the USA with at least a 5-year history was explored for IMGs in the current roster using the AMA residency and fellowship database in 2020. Demographic and geographic data were summarized. RESULTS: A total of 230 general surgery residency program were included. Programs were distributed among 46 (92%) states. Of a total 6304 categorical general surgery residents, 573 (9%) were IMGs. Florida (USA) had the highest total number of current IMG general surgery residents with 64. The highest percentage of current IMG residents was found in Maryland (USA) with 31%. IMGs obtained their medical degrees from 76 different countries worldwide. Grenada was the country with the highest origin of IMGs with 77 residents. Central/North America had the highest origin of IMGs with 217 (38%). CONCLUSIONS: IMGs make up a small portion of current general surgery residents in USA programs. Some states host more IMGs than others. Particular countries have contributed more IMGs than others. More research is needed to the challenges facing IMGs and come up with novel solutions for them.

Neglected Tropical Diseases in Lebanon.

INTRODUCTION: Neglected tropical diseases (NTDs) are highly endemic and distributed within the Middle East and North Africa (MENA) region, affecting an estimated 65 million people. Lebanon suffers from several NTDs as they are either endemic in the country or imported via expats residing in endemic regions, refugees, and foreign labor force. The Syrian crisis and the displacement of refugees to Lebanon have made the country the largest host of refugees per capita right after the Syrian crisis in 2011, peaking in the year of 2013. Additionally, foreign labor in Lebanon come from different countries in Africa and Asia that are endemic with certain NTDs. The Lebanese diaspora is approximately twice the number of those residing in the country and is distributed throughout the continents carrying the risk of importing new NTDs. MATERIALS AND METHODS: A descriptive study about the prevalence of NTDs in Lebanon, their distribution, and factors contributing to spread was performed. The Lebanese Ministry of Public Health (LMPH) database regarding reportable transmissible diseases was reviewed for reportable NTDs between 2002 and 2020 in relation to age, gender, prevalence, and geographical distribution. The medical literature was searched using several engines looking for all reports about NTDs in Lebanon, those relevant to regions hosting Lebanese diaspora, and countries where the refugees and migrant workers came from. RESULTS: Only leishmaniasis, leprosy, echinococcosis, schistosomiasis, and rabies are mandatorily reportable NTDs by the LMPH. Additionally, case reports about fasciolosis, ascaridiosis, and Dengue were reported from Lebanon. The presence of the Syrian refugees in the country affected the prevalence of leishmaniasis and rabies. The most prevalent NTD in Lebanon is cutaneous leishmaniasis. The Lebanese diaspora reside mainly in South America, Africa, and in some Arab states known to be endemic with certain NTDs. CONCLUSION: Little information is known about NTDs in Lebanon. The country is at an increased risk of experiencing several new NTDs due to refugee influx, foreign labor, economic crisis, and ever-growing number of Lebanese seeking work opportunities abroad. More information is needed to assess the true burden of NTDs in Lebanon and the future steps to contain and mitigate their effects.

COVID-19 in conflict region: the arab levant response.

BACKGROUND: COVID-19 has hit the world in an unprecedented way causing serious repercussions on several aspects of our life. Multiple determinants have affected various nations' level of success in their responses towards the pandemic. The Arab Levant region in the Middle East, notoriously known for repeated wars and conflicts, has been affected, similarly to other regions, by this pandemic. The combination of war, conflict, and a pandemic brings too much of a burden for any nation to handle. METHODS: A descriptive analysis of data obtained from the health departments of various Arab Levant Countries (ALC) was performed. ALC include Lebanon, Syria, Jordan, Iraq and Palestine. The data collected involves incidence, recovery rate, case fatality rate and number of tests performed per million population, Global Health Security index, government stringency index, and political stability index. The information obtained was compared and analyzed among the ALC and compared to global figures. An extensive electronic literature search to review all relevant articles and reports published from the region was conducted. The 2019 Global Health Security (GHS) index was obtained from the "GHS index" website which was made by John Hopkins University's center for health security, the Nuclear threat Initiative (NTI) and the Economist Intelligence Unit (EIU). Government stringency index and political stability index were obtained from the University of Oxford and the website of "The Global Economy", respectively. Other world governance indicators such as government effectiveness were obtained from the World Bank website. RESULTS: In terms of incidence of COVID-19, Iraq has the highest with 9665 per one million population, Syria the lowest at 256 per million. Deaths per million population was highest in Iraq at 237, and the lowest in Syria at 12. As for number of tests per million population, Lebanon ranked first at 136,033 with Iraq fourth at 59,795. There is no data available for the tests administered in Syria and subsequently no value for tests per million population. In terms of recoveries from COVID-19 per million population, Iraq had the highest number at 7903 per million, and Syria the lowest at 68 per million. When compared as percent recovery per million, Palestine ranked first (84%) and Syria last (27%). The government response stringency index shows that Jordan had the highest index (100) early in the pandemic among the other countries. Palestine's index remained stable between 80 and 96. The other countries' indices ranged from 50 to 85, with Lebanon seeing a drop to 24 in mid-August. Even with improved stringency index, Iraq reported an increased number of deaths. CONCLUSION: In countries devastated by war and conflict, a pandemic such as COVID-19 can easily spread. The Arab Levant countries represent a breeding ground for pandemics given their unstable political and economic climate that has undoubtedly affected their healthcare systems. In the era of COVID-19, looking at healthcare systems as well as political determinants is needed to assess a country's readiness towards the pandemic. The unrest in Lebanon, the uprising in Iraq, the restrictions placed on Syria, and the economic difficulties in Palestine are all examples of determinants affecting pandemic management. Jordan, on the contrary, is a good example of a stable state, able to implement proper measures. Political stability index should be used as a predictor for pandemic management capacity, and individual measures should be tailored towards countries depending on their index.

The Association Between the Syrian Crisis and Cutaneous Leishmaniasis in Lebanon.

INTRODUCTION: Displacement of refugees from highly endemic areas of leishmaniasis to adjacent countries is associated with the spread of Leishmania. Syria is a country with a known high endemicity for cutaneous leishmaniasis and the presence of Syrian refugees in Lebanon has contributed to the re-emergence of the disease. The aim of this article is to evaluate the burden of cutaneous leishmaniasis in Lebanon in view of the presence of a large number of Syrian refugees. METHODS: Data regarding all cases of leishmaniasis were collected from reports by the Lebanese Ministry of Public Health-Epidemiology Surveillance (LMPH-ESU), and the World Health Organization (WHO) between 2005 and 2018. All cases were reviewed in terms of area of residence, age and gender, clinical presentation, treatment, and outcome. An extensive literature review was conducted using "PubMed", "Medline", and "Google Scholar". RESULTS: The annual number of leishmaniasis cases recorded in Lebanon between 2005 and 2011 ranged between 0 and 6 cases. In 2012, this number increased to 1275 cases and dropped to 263 in 2018, where all those infected were Syrian refugees from Aleppo, with zero cases of local transmission. Seventy-two percent of cases were seen in patients aged < 20 years. The predominant species of Leishmania was L. tropica followed by L. major. CONCLUSION: Lebanon was affected by leishmaniasis following the Syrian crisis, and the influx of refugees to the country. Accurate disease monitoring and strategic training of healthcare personnel based within refugee camps are essential for proper containment. Preventative measures remain the best way to avoid both local and adjacent spread of leishmaniasis.

Measles and mumps outbreaks in Lebanon: trends and links.

BACKGROUND: Lebanon has experienced several measles and mumps outbreaks in the past 20 years. In this article, a case-based surveillance of both measles and mumps outbreaks in Lebanon was carried out in an attempt to outline factors contributing to the failure of elimination plans and to provide potential solutions. The relationship between the outbreaks of both diseases was described and explored. METHODS: A retrospective descriptive study of confirmed cases of measles and mumps in Lebanon between 2003 and 2018 collected from the Lebanese Ministry of Public Health Epidemiological Surveillance Unit public database was carried out. The information collected was graphically represented taking into consideration dates of reported cases, age groups affected, and vaccination status. RESULTS: The mean number of measles cases was 150.25 cases/year in the 1-4 years age group, 87 cases/year in individuals aging between 5 and 14, and 63.68 cases/year in those > 14 years old. In the latter group, only 18.05% were unvaccinated. The mean number of mumps cases was 30.4 cases/year in the < 4 year age group and 53.8 cases/year in the 10-19 years age group. During the study period, every spike in measles cases was followed by a similar spike in mumps. 9.66% of measles cases occurred in individuals who received at least 2 doses of the vaccine, 52.26% in the unvaccinated, and 38% in those whose vaccination status was undetermined. CONCLUSIONS: Measles in Lebanon is a disease of the pediatric population, but adults remain at risk. Outbreaks of mumps followed those of measles and were mainly among adolescents. Presence of a large number of Syrian refugees in the country may further complicate the situation. Vaccination activities need to be intensified.