A survey-based study about burnout among postgraduate medical trainees: implications for leaders in healthcare management.

Introduction: The goal of the study is to assess burnout among postgraduate medical trainees, evaluate the association with sociodemographic features and offer potential wellness strategies for leaders responsible for their education, training, management, and wellbeing. Methods: The Oldenburg Burnout Inventory was used. The web-based, voluntary, and anonymous survey was sent to postgraduate medical trainees from various specialties and all years of training in a tertiary medical center in Beirut, Lebanon. Additional questions were added after the survey regarding reporting channels for burnout and possible interventions for wellbeing. Results: The total number of valid responses are 188. The prevalence rates of high burnout are 37.2% for disengagement and 51.1% for exhaustion. There is a significant difference between the mean of exhaustion and gender (p = 0.003). There is a significant difference between the mean of disengagement and year of training (p = 0.017). There is a significant difference between the mean of exhaustion and year of training (p = 0.029). There is a significant difference between the frequency of disengagement and year of training (p = 0.027). Conclusion: The study reveals how postgraduate medical training program is impacted by the existing challenges from social, health, and financial standpoint, along with the instabilities encountered such as multiple wars and port blast in 2020 and how these variables aggravate burnout. Burnout severely impacts the education and training of PGMT and promoting wellbeing can help reverse the process. Findings contribute to establishing effective strategic interventions for leaders in healthcare management to adopt.

Comparative analysis of partial versus radical nephrectomy for renal cell carcinoma: Is oncologic safety compromised during nephron sparing in higher stage disease?

Objectives: Over the past 20 years, the utility of partial nephrectomy (PN), compared to radical nephrectomy (RN), for the management of localized renal cell carcinoma (RCC) has progressively increased, particularly for larger and more complex masses. We sought to compare the recurrence-free survival (RFS) outcomes of PN versus RN in a single-institution cohort. Methods: Between 2002 and 2017, 228 patients underwent RN or PN for lcT1a-T2b, N0M0 RCC at a single tertiary referral center, performed by five surgeons. The clinical end point result was (local or distant) RFS. Univariate and multivariate (cox regression) models were used to evaluate the association between type of surgery (PN vs. RN) and RFS, in the overall cohort and in a subgroup of patients with cT1b. Results: The median age was 59 (interquartile range [IQR] 48-66), and the median tumor size was 4.5 cm (IQR 3-7). There were 128 PN and 100 RN. Over a median follow-up of 4.2 years (IQR 2.2-6.9), the Kaplan-Meier analysis showed no significant RFS difference between PN and RN (logrank P = 0.53). On multivariate analysis, pathologic stage ≥T2a, Fuhrman Grade ≥3, and chromophobe histology were associated with a worse RFS. PN was not significantly associated with diminished RFS (Hazard ratio [HR] 1.78, 95% confidence interval [CI] 0.74-4.3, P = 0.199) in the overall cohort compared to RN. However, in the cT1b subgroup, PN was associated with a significant increase in recurrence compared to RN (HR = 12.4, 95% CI 1.45-133.4, P = 0.038). Conclusions: Our institutional data highlight the possibility of compromise in RFS for clinically localized RCC treated with PN compared to RN, particularly for larger and more complex masses. These data raise concern, especially in light of the nonproven association of survival benefit of PN over RN, warranting future randomized prospective studies for further evaluation.

Epidemiology and composition of nephrolithiasis in a Lebanese tertiary care center: A descriptive study.

Introduction: Nephrolithiasis is a common affliction with a prevalence of 12% in men and 7% in women. The incidence rate diverges with geographic location. Arab countries report high nephrolithiasis prevalence rates, with Saudi Arabia being the highest (20.1%). To date, there is little knowledge about the demographics and composition of stones in Lebanon. Methods: A retrospective chart review was performed on stone composition at the American University of Beirut Medical Center, between 2005 and 2018. Patients' demographics and stone characteristics were obtained from electronic medical records. Analysis of frequencies and Chi-square test were adopted for potential risk factor correlations by the Statistical Package for the Social Sciences (SPSS). Results: A total of 626 stone analyses were performed. Male patients predominated (69%). The mean age was 46.58 ± 16.5 years, and mean body mass index was 28.63 ± 5.6, for both sexes. Calcium oxalate was the most predominant stone in both sexes (70%). Uric acid stones followed (~16%), and calcium oxalate phosphate stones were the third most common (5%). Incidence of kidney stones peaks in the summer, with 11.86% presenting in July. Around 60% presented with flank pain to the Emergency Department, and 32% ended up with spontaneous passage of stones by medical expulsive therapies alone, with no further surgical intervention. Diabetes and hypertension were significantly correlated with stone recurrence in our cohort. Conclusion: There is a significant gender disparity in stone prevalence in Lebanon. Calcium oxalate is the most common type in both sexes. Future investigations of dietary and environmental factors are recommended from our region.

The R.E.N.A.L score's relevance in determining perioperative and oncological outcomes: a Middle-Eastern tertiary care center experience.

Objective: The aim of this study is to evaluate the significance of the R.E.N.A.L nephrometry scoring system in predicting perioperative and oncological outcomes and determining the surgical approach of choice for kidney tumors.Patients and Methods: Our study retrospectively reviewed outcomes from the year 2002 to 2017. Mann-Whitney U test was used to compare continuous variables and chi-square test was used to compare categorical variables. Kaplan-Meier estimates and multivariable cox proportional hazard regression were performed to determine an association between the different R.E.N.A.L categories and disease recurrence or mortality. Results: A total of 325 patients underwent kidney surgery The most common R.E.N.A.L score category in our cohort study was intermediate (41.2%), followed by low, (33.2%) and high (25.5%). Patients with a high R.E.N.A.L score had worse perioperative outcomes compared to those with a low R.E.N.A.L score. High R.E.N.A.L score patients were 3 times more likely to receive blood transfusions compared to those with a low R.E.N.A.L score (19.4% vs 6.3%, p = 0.018), and a statistically significant longer hospital length of stay was also observed between the two groups (median 4.5 vs 4 days, p = 0.0419). In addition, the only predictor of disease recurrence or mortality was a high R.E.N.A.L score (Hazard Ratio (HR) 3.65, 95% Confidence Interval (CI) 1.05-12.7, p = 0.041). Conclusion: Our study sheds light on the use of R.E.N.A.L nephrometry score in predicting perioperative, postoperative, and oncological outcomes. Such findings may play a role in optimizing surgical approaches and pre-operative patient counseling.

Pyocolpos: A rare cause of recurrent abdominal pain - Always insist on a thorough physical examination.

Thorough physical examination is a must for proper diagnosis of medical diseases and to elucidate all physical findings. Abdominal pain is a very common presentation to Emergency Department, compromising 5%-10% of all visits, and around a quarter are discharged with no particular diagnosis. Pyocolpos is one of those presentations that requires a thorough physical examination, including that of the external genitalia. A 3-year-old girl presented with recurrent history of abdominal pain and a recent history of fever with acute abdomen picture-like presentation, with difficulty voiding over the past few days. She was previously assessed for recurrent abdominal pain, without any identifiable etiology. Upon inspection for indwelling catheter insertion, absence of the vaginal introitus was noted with a bulging mass and an imperforate hymen. Pyocolpos was diagnosed and drained following hymenotomy. Pyocolpos is a rare complication of hydrocolpos. Enlarged vagina causes extrinsic compression to nearby structures, such as the bladder trigone and ureters, causing hydronephrosis, hydroureter, and other sequel including acute kidney injury and urosepsis. An imperforate hymen must be considered in the differential for chronic and recurrent abdominal pain, and can be easily identified by a thorough physical examination, including that of the external genitalia, which is a must in today's every medical practice.

Prevalence of Y-chromosomal microdeletions and karyotype abnormalities in a cohort of Lebanese infertile men.

BACKGROUND: Male infertility is the main issue that accounts for 50% of infertility in couples. There are about 25% of men suffering from nonobstructive infertility with chromosomal abnormalities and/or microdeletions of the long arm of the Y-chromosome. MATERIALS AND METHODS: A retrospective chart review was performed on 241 men who performed Y-chromosome microdeletions and karyotype testing. RESULTS: Six patients had microdeletions. Three patients had AZFc microdeletion, of which one had both AZFc/d microdeletions. Three patients had AZFb/c microdeletion. There was no AZFa microdeletion. One out of the six patients had abnormal karyotype (mos, X[17]/46, XY[13]). Four patients were azoospermic, two had severe oligospermia, with sperm count <5 million/ml, and two patients had small size testicles on ultrasound. All were advised microsurgical testicular sperm extraction. Three were done, and one was successful resulting in sperm retrieval. The most common karyotype abnormalities were 47, XXY (Klinefelter syndrome) in 27% of cases. CONCLUSION: Laboratory genetic testing is advised for males with nonobstructive infertility. Any abnormal finding can yield substantial consequences to assisted reproductive techniques or fertility treatment. It can offer a stable diagnosis for those with infertility issues. It is important to conduct counseling and routine genetic testing before assisted reproductive techniques.

Burnout among postgraduate medical trainees in Lebanon: Potential strategies to promote wellbeing.

Objective: Burnout is a widespread issue in healthcare for many years. Lebanon combatted political and economic crises before the coronavirus disease 2019 (COVID-19) pandemic, in addition to the port explosion in August 2020. The study aimed to identify the determinants of personal burnout, patient-related burnout, and work-related burnout among postgraduate medical trainees (PGMT) and evaluate its relationship with sociodemographic characteristics. Design: A cross-sectional study utilized the Copenhagen Burnout Inventory (CBI) involving electronic, voluntary, and anonymous survey. The survey was completed by 188 PGMT including residents and fellows from all specialties and all levels of training. Results: The prevalence rates are 68.6% for personal burnout, 63.3% for work-related burnout, and 35.1% for patient-related burnout. Conclusion: Results improve our understanding of the phenomenon of burnout, and the role of program leadership in shaping the impact of burnout on training and promoting wellbeing of PGMT. Discussion focuses on providing potential wellbeing strategies for program directors to follow for mitigating burnout.

Renal and Lung Cysts in Birt-Hogg-Dubé Syndrome: A Continuum of the Same Disorder.

Birt-Hogg-Dubé (BHD) syndrome is a rare autosomal-dominant disorder, affecting multiple organs, mostly the skin, lungs, and kidneys. The prevalence of BHD syndrome is difficult to define given the rarity of the disease. Patients present most often with primary spontaneous pneumothorax. Renal tumors are a characteristic finding in BHD, and are often bilateral and multifocal and of the chromophobe and oncocytoma variant. Very scarce reports have highlighted the presence of simple renal cysts, as the only phenotypical renal manifestation, in BHD patients. Herein, we highlight two novel cases of bilateral multiple renal and pelvic cysts, in two females with genetically proven BHD syndrome, doubting a potential association with BHD syndrome.

Acute Kidney Injury Post-cardiac Surgery in Infants and Children: A Single-Center Experience in a Developing Country.

Introduction: The incidence of acute kidney injury (AKI) in pediatric patients following cardiac surgery varies between 15 and 64%, with a mortality rate of 10-89% among those requiring dialysis. This variation in the incidence and mortality of AKI across studies is probably due to the inconsistent definitions used for AKI. The purpose of this study is to present our experience with AKI post-cardiac surgery with emphasis on predisposing or aggravating factors. Patients and Methods: We evaluated the incidence of AKI using the KDIGO criteria in 150 infants and children undergoing cardiac surgeries between 2015 and 2017. Post-operatively, all patients were admitted to the pediatric intensive care unit (PICU) at a tertiary care center in a developing country. This is a retrospective chart review in which data collected included age, gender, type of heart disease, prior cardiac surgeries, RACHS-1 category, and pre- and post-operative creatinine levels. Neonates were not included in this study. Results: Six percent of the studied patients were below 1 year of age, 84% 1-10 years, and 10% 10-18 years. Fourteen patients (9.3%) developed AKI. Patients with cyanotic heart disease were more prone to develop AKI (78%) compared to those with non-cyanotic heart disease (44%). Children with AKI had a higher length of stay in PICU, 2.56 ± 1.44 vs. 4 ± 2.66 (p- 0.02). Serum lactic acid was higher in patients who developed AKI with a mean value of 6.8 ± 6.9 vs. 2.85 ± 1.55 mmol/l in the non-AKI group (p- 0.03). Lower hemoglobin levels and hyperlactic acidemia were significantly more prevalent in the AKI group. There were five deaths in this series (3.3%), and four of those (80%) were in the AKI group. Conclusion: Using the KDIGO criteria, the incidence of AKI in infants and children following cardiac surgery was 9.3%. This is slightly lower than in previously published studies where the range was between 15 and 64%. Children with cyanotic cardiac disease, hyperlactic acidemia, and anemia were more prone to developing AKI. Identifying patients at risk might help decrease the risk of post-operative AKI.

Comparative analysis of histopathological subtypes of renal cell carcinoma in the Middle East compared to other world regions.

INTRODUCTION: Renal cell carcinoma (RCC) has various histopathological tumor subtypes which have a significant implication on the oncological outcome of these patients. We aimed to evaluate the distribution of RCC subtypes presenting at a tertiary care center in the Middle East, in comparison to the distribution reported in different geographic areas worldwide. METHODS: A retrospective chart review was conducted on all patients who underwent partial or radical nephrectomy for RCC at the American University of Beirut Medical Center between January 2012 and January 2018. Data on histologic subtypes were compiled and compared to representative series from different continents. RESULTS: One hundred and seventy-nine patients with RCC were identified, of whom 122 (68.2%) were classified as clear cell, 30 (16.8%) as papillary, 17 (9.5%) as chromophobe, and 10 (5.6%) as unclassified. When compared to other regions of the world, this Middle Eastern series demonstrated a higher prevalence of the chromophobe subtype compared to Western populations (9.5% in the Middle East vs. 5.3% in the US and 3.1% in Europe) and a lower prevalence of clear cell subtype (68.2% in the Middle East vs. 78.7% in the US and 85.8% in Europe). Conversely, there was a higher prevalence of papillary RCC in the Middle East (16.8%) compared to North America (13.1%, 95% confidence interval [CI]: 12.7-13.6), Europe (11.1%, 95% CI: 10.0-12.1), and Australia (10.2%). The prevalence of chromophobe and clear cell RCC in the Middle East was similar to that reported in South America. CONCLUSIONS: The distribution of RCC subtypes in this Middle Eastern cohort was significantly different from that reported in the Western hemisphere (Europe and the US) but similar to that reported in South America and Australia. These findings may point to a possible genetic predisposition underlying the global variation in distribution.

Isolated Solitary Lung Nodule in a Patient With Idiopathic Pulmonary Fibrosis and Concomitant Prostate Cancer: A Challenging Diagnosis.

Prostate cancer is the most commonly diagnosed malignancy and the second most common cause of death in men after lung cancer. Isolated pulmonary metastasis from prostate cancer, without bone or lymph node involvement, is rare and accounts for less than 1% of cases. The diagnosis of solitary lung metastasis is even more challenging in patients with concomitant pulmonary disease and often mandates tissue biopsy from the lung nodule. We herein present a case of an elderly man with idiopathic pulmonary fibrosis who presented with a solitary lung nodule three years after a laparoscopic radical prostatectomy for localized prostate cancer. Initially thought as a primary lung lesion secondary to his pulmonary fibrosis, further workup and ultimately a lung segmentectomy proved a metastatic prostatic adenocarcinoma. The serum prostatic specific antigen dropped to nadir following resection, and he remained stable six months later.

A Newborn with Retrovesical Cysts and an Ipsilateral Multicystic Dysplastic Kidney.

We present a clinical imaging question focusing on a newborn with known prenatal history of a multicystic dysplastic kidney, and incidental ipsilateral retrovesical seminal vesical cysts, raising the diagnosis of Zinner syndrome. The diagnosis is challenging in this age group. Surgical management is generally proposed for symptomatic cases at an older age.

Genitourinary Interventions in Autosomal Dominant Polycystic Kidney Disease: Clinical Recommendations for Urologic and Transplant Surgeons.

Autosomal dominant polycystic kidney disease is the fourth most common single cause of end-stage renal disease worldwide with both renal and extrarenal manifestations, resulting in significant morbidity. Approaches to the management of this disease vary widely, with no broadly accepted practice guidelines. Herein, we reviewed the various surgical and interventional management options that are targeted toward treating the symptoms or addressing the resulting kidney failure. Novel treatment modalities such as celiac plexus blockade and renal denervation appear to be promising in pain relief; however, further studies are lacking. Renal cyst decortication seems to have a higher success rate in targeting cyst-related pain compared with aspiration only. In terms of requiring major surgical intervention, such as need and timing of native nephrectomy, there are several considerations when deciding on transplantation with or without a pretransplant native nephrectomy. Patients who are not candidates for native nephrectomy may consider transcatheter arterial embolization. Based on our review of the contemporary indications for genitourinary interventions in the management of autosomal dominant polycystic kidney disease, we propose an algorithm that depicts the decision-making process on assessing the indications and timing of native nephrectomy in patients with end-stage renal disease awaiting transplant.

Kidney and Metabolic Phenotypes in Glycogen Storage Disease Type-I Patients.

Patients and Methods: A retrospective chart review of 32 GSD- I patients, followed at the American University of Beirut Medical Center, between 2007 and 2018 was conducted. Diagnosis was confirmed by enzymatic and/or genetic studies. Clinical presentation, growth, and kidney outcome were assessed. All patients were evaluated for body mass index, blood parameters of metabolic control including uric acid, alanine, lactic acid, and triglycerides in blood. Kidney evaluation included creatinine clearance, microalbuminuria, citraturia, and calciuria as well as urine microalbumin/creatinine ratio. Results: Almost one third of GSD-I patients developed microalbuminuria. This was detected below 7 months of age in 36% of patients who required early treatment with ACEI with significant reduction in albuminuria. Kidney stones were present in 6% and were associated with hypercalciuria and hypocitraturia. Poor metabolic control reflected by hyperuricemia, lactic acidosis, and hyperalaninemia were noted only in patients who developed microalbuminuria. Conclusion: Glomerular injury may appear in early infancy in poorly controlled patients. Adequate metabolic control and ACEI therapy may improve kidney outcome in GSD I patients. Plasma alanine appears to be a promising and reliable marker reflecting metabolic control in GSD-I patients.

A Very Low-Positioned Aortic Bifurcation.

Anomalies of the aortoiliac arteries are rarely reported and are generally discovered incidentally on imaging performed mostly for investigation of other medical concerns. While aortic bifurcation is typically reported at the fourth lumbar vertebra, variations are possible. We present a case with very low aortic bifurcation, almost at the level of S2, with various other anomalies including a corkscrew left common iliac artery passing just anterior to the bladder dome with pulsation noted during cystoscopy. An ectopic right kidney was also noted. To our knowledge, these vascular anomalies have not been reported previously.

Differentiation of Urothelial Carcinoma into Two Distinct Subtypes, Glandular and Squamous, in Three Different Organs.

Urothelial carcinoma (UC) is a unique entity with different histological variants: squamous, glandular, small cell, micropapillary, sarcomatoid, and plasmacytoid. Each of those subtypes behaves differently. As such, and in many scenarios, an accurate histological diagnosis is of paramount importance to dictate the therapeutic approach. We hereby present a unique case of urothelial carcinoma that differentiated into two distinct histological subtypes, squamous and glandular, in three different organs within the genitourinary tract. We also describe the pathological and clinical differences entailed between the two histological variants in bladder and upper urinary tract urothelial carcinoma.

Childhood and adolescent idiopathic urethritis: what does the current literature say?

INTRODUCTION: Idiopathic urethritis (IU) is a known entity in the childhood and adolescent age groups and is described as blood spotting of the underwear in these populations. Typically, IU presents clinically as terminal void haematuria or blood spotting, accompanied with dysuria, occasional suprapubic pain and rarely constitutional symptoms. Sometimes IU may progress to formation of urethral strictures. It carries a high morbidity because of its chronicity and recurrent course, which often persists to puberty. In spite of no single aetiology being confirmed, several treatment approaches have shown some efficacy. Although no consensus has yet been established, the consideration of previous authors' experience and expertise may contribute to the development of a possible unified algorithm. AIM: This article considers IU, collecting pertinent data and case series from the literature. The authors attempt to describe all presumptive aetiologies, endoscopic findings with established grading classifications and finally the various treatment modalities proposed. In addition, highlights from the senior's author experience regarding this entity including endoscopic, radiographic and histological images are mentioned. METHODS: Retrospective review and analysis of all relevant articles present on PubMed, SCOPUS and Cochrane Library from the time of inception to the date of first submission. RESULTS: A total of 19 series concerning IU have been reported since year 1971 to present time (Table 1). Many aetiologies have been postulated, but some have been refuted, including infectious pathogens. Children with dysfunctional voiding and meatal stenosis are more prone to exhibit IU. A variation in the urethral milieu during the prepubertal period, secondary to systematic hormonal alteration, may lead to squamous cell metaplasia resulting in IU and possible urethral strictures. Grading classifications for IU are described. Up to 20% of IU may develop urethral strictures. Various treatment approaches are discussed. CONCLUSION: A summary of current understanding of the pathogenesis and spectrum of IU has been achieved. Successful treatment can be achieved with steroids and dysfunctional voiding protocols. It may be possible to develop a consensus unified management algorithm.

A large bi-lobed classic renal angiomyolipoma with vena caval extension.

Renal angiomyolipomas (AMLs) are the most common benign renal tumors encountered, and composed of 3 components: mature adipose tissues, smooth muscles, and blood vessels. Mostly asymptomatic and discovered incidentally, the classic type of AMLs rarely extend to involve great vessels. Radiological confirmation of such lesions is paramount for diagnosis and planned intervention. Management of AMLs is based on clinical presentation and varies from active surveillance to invasive surgical interventions. A case of sizeable classic AML with extension to inferior vena cava is presented here, with successful tumor resection performed after complete liver mobilization. A literature review and a summary of similar cases are also presented. A multidisciplinary approach is required for proper and precise radiological diagnosis to achieve an adequate surgical resection, which might sometimes be complicated and complex, as in this current case.