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Good or best practice statements: Proposal for the operationalisation and implementation of GRADE guidance
Get PDFAn evidence-based approach is considered the gold standard for health decision-making. Sometimes, a guideline panel might judge the certainty that the desirable effects of an intervention clearly outweigh its undesirable effects as high, but the body of supportive evidence is indirect. In such cases, the application of the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach for grading the strength of recommendations is inappropriate. Instead, the GRADE Working Group has recommended developing ungraded best or good practice statement (GPS) and developed guidance under which circumsances they would be appropriate. Through an evaluation of COVID-1- related recommendations on the eCOVID Recommendation Map (COVID-19.recmap.org), we found that recommendations qualifying a GPS were widespread. However, guideline developers failed to label them as GPS or transparently report justifications for their development. We identified ways to improve and facilitate the operationalisation and implementation of the GRADE guidance for GPS. Herein, we propose a structured process for the development of GPSs that includes applying a sequential order for the GRADE guidance for developing GPS. This operationalisation considers relevant evidence-to-decision criteria when assessing the net consequences of implementing the statement, and reporting information supporting judgments for each criterion. We also propose a standardised table to facilitate the identification of GPS and reporting of their development. This operationalised guidance, if endorsed by guideline developers, may palliate some of the shortcomings identified. Our proposal may also inform future updates of the GRADE guidance for GPS. © 2023 BMJ Publishing Group. All rights reserved
Typhoid Fever in the Eastern Mediterranean Region: A Systematic Review, 1990–2021
Get PDFThe occurrence and antimicrobial resistance (AMR) of typhoid fever in the WHO Eastern Mediterranean Region (EMR) are poorly characterized. Robust surveillance data are needed to inform strategies for typhoid control and prevention in the region. We conducted a systematic review of typhoid fever occurrence, complications, and AMR patterns in EMR countries. We identified 70 studies published from 1990 to 2021, including a total of 44,541 cases with blood culture confirmed typhoid fever in 12 EMR countries, with 48 (69%) studies and 42,008 cases from Pakistan. Among 56 studies with AMR data, fluroquinolone (68% of 13,013 tested isolates), and multidrug resistance (40% of 15,765 tested isolates) were common. Forty (57%) of the 56 studies were from Pakistan, and all reports of extensively drug resistant Salmonella Typhi (48% of 9,578 tested isolates) were from studies in Pakistan. Our findings support the need for continued efforts to strengthen surveillance and laboratory capacity for blood-culture detection of typhoid fever in the region, including data from an ongoing collaboration among CDC, the American University of Beirut, and the WHO EMR office. Copyright © 2023 The American Society of Tropical Medicine and Hygiene
The impact of forced displacement: trauma, increased levels of inflammation and early presentation of diabetes in women Syrian refugees
Get PDFBackground Forced displacement and war trauma cause high rates of post-traumatic stress, anxiety disorders and depression in refugee populations. We investigated the impact of forced displacement on mental health status, gender, presentation of type 2 diabetes (T2D) and associated inflammatory markers among Syrian refugees in Lebanon. Methods Mental health status was assessed using the Harvard Trauma Questionnaire (HTQ) and the Hopkins Symptom Checklist-25 (HSCL-25). Additional metabolic and inflammatory markers were analyzed. Results Although symptomatic stress scores were observed in both men and women, women consistently displayed higher symptomatic anxiety/depression scores with the HSCL-25 (2.13 ± 0.58 versus 1.95 ± 0.63). With the HTQ, however, only women aged 35–55 years displayed symptomatic post-traumatic stress disorder (PTSD) scores (2.18 ± 0.43). Furthermore, a significantly higher prevalence of obesity, prediabetes and undiagnosed T2D were observed in women participants (23.43, 14.91 and 15.18%, respectively). Significantly high levels of the inflammatory marker serum amyloid A were observed in women (11.90 ± 11.27 versus 9.28 ± 6.93, P = 0.036). Conclusions Symptomatic PTSD, anxiety/depression coupled with higher levels of inflammatory marker and T2D were found in refugee women aged between 35 and 55 years favoring the strong need for psychosocial therapeutic interventions in moderating stress-related immune dysfunction and development of diabetes in this subset of female Syrian refugees. © The Author(s) 2023. Published by Oxford University Press on behalf of Faculty of Public Health
External validation of a clinical prediction model in multiple sclerosis
Get PDFBackground: Timely initiation of disease modifying therapy is crucial for managing multiple sclerosis (MS). Objective: We aimed to validate a previously published predictive model of individual treatment response using a non-overlapping cohort from the Middle East. Methods: We interrogated the MSBase registry for patients who were not included in the initial model development. These patients had relapsing MS or clinically isolated syndrome, a recorded date of disease onset, disability and dates of disease modifying therapy, with sufficient follow-up pre- and post-baseline. Baseline was the visit at which a new disease modifying therapy was initiated, and which served as the start of the predicted period. The original models were used to translate clinical information into three principal components and to predict probability of relapses, disability worsening or improvement, conversion to secondary progressive MS and treatment discontinuation as well as changes in the area under disability-time curve (ΔAUC). Prediction accuracy was assessed using the criteria published previously. Results: The models performed well for predicting the risk of disability worsening and improvement (accuracy: 81%–96%) and performed moderately well for predicting the risk of relapses (accuracy: 73%–91%). The predictions for ΔAUC and risk of treatment discontinuation were suboptimal (accuracy < 44%). Accuracy for predicting the risk of conversion to secondary progressive MS ranged from 50% to 98%. Conclusion: The previously published models are generalisable to patients with a broad range of baseline characteristics in different geographic regions. © The Author(s), 2022
Wars Of The Warez; The Never-Ending Battle For Recognition And Social Capital In The Denovo Warewind
Get PDFThere exists an online community known as the Warez Scene, which focuses on downloading, cracking, and distributing paid licensed software/games for free in the form of piracy. These pirates, as they call themselves, have one goal: to remove the digital protection that companies have placed in these games. Such digital protections, known as DRMs, exist to make sure a digital product is accessed and used via legal and legitimate means. However, crackers within the scene spend days, even weeks working to infiltrate this protection system, which manifests in different ways within each digital product. They do this work to release said digital product for free and thus secure no financial gain.
In this thesis, I ponder the question, why? Why do crackers, who are sometimes teams of people, work around the clock to infiltrate a DRM and release the cracked software to the public? Through netnography I narrowed it down to three reasons, each with a dedicated chapter: (1) Aspiration and Competition, this is where I look into one part of motivation and how competition drives these groups to crack bigger and harder games. (2) Creativity and Problem Solving, in this Chapter I show how cracking is considered an art. I show different difficulty levels of cracking and how these DRM companies find new ways to protect their game, and in turn, how these crackers find ways to infiltrate this protection. And finally (3) the Aesthetics of the Warez Scene, where I look into the warez scene as a whole through the lens of art. I look at where the scene is situated online and how its artistic representation helps fuel these crackers to take part in a “fantasy” online world.
It is important that we look into this to find behavioral patterns to figure out how precarious labor pertains to not only legal forms of labor, but underground methods as well. Moreover, this thesis intends to expand on the existing scholarship that exists on the warez scene
Perfluorooctanoic Acid and Perfluorooctane Sulfonate in Human Milk: First Survey from Lebanon
Get PDFHuman milk is the primary source of nutrition for infants in their first year of life. Its potential contamination with perfluorooctanoic acid (PFOA) and perfluorooctane sulfonate (PFOS), a group of toxic man-made chemicals, is a health concern that may threatens infants’ health. Our study aims to assess the levels of PFOA and PFOS in the breast milk of Lebanese lactating mothers and the maternal factors associated with their presence. High-performance liquid chromatography (HPLC) coupled with a Micromass Quattro micro API triple quadrupole mass spectrometer was used to detect the level of contamination in 57 collected human milk samples. PFOA and PFOS were present in 82.5% and 85.7% of the samples, respectively, while PFOA levels ranged between 120 and 247 pg/mL with a median of 147 pg/mL, and those of PFOS ranged between 12 and 86 pg/mL with a median of 27.5 pg/mL. The median contamination for PFOA exceeded the threshold set by the European Food Safety Authority (EFSA) (60 pg/mL); however, that of PFOS was below the threshold (73 pg/mL). The consumption of bread, pasta, meat, and chicken more than twice per week and that of white tubers and roots at least once per week was significantly associated with higher levels of PFOA (p < 0.05). No significant association was found between maternal age, BMI, parity, level of education, place of residence, source of water used, and smoking with the levels of PFOA and PFOS in the human milk. Additionally, the consumption of cereals at least twice per week was significantly associated with higher levels of PFOS. These findings call for actions to improve the local environmental and agricultural practices, and the regulations and standards for inspecting imported food. It is important to highlight that the benefits of breastfeeding outweigh the reported contamination with PFOS and PFOA in our study. © 2023 by the authors
Knowledge, attitudes, and practices of pediatricians in relation to breastfeeding support: A national survey in Lebanon
Get PDFBackground Rates of breastfeeding (BF) remain suboptimal despite overwhelming evidence for its benefits to the mother and child. Pediatricians play an important role in supporting breastfeeding (BF). In Lebanon, the rates of both exclusive and continued BF are critically low. The objective of this study is to examine the knowledge, attitudes and practices (KAP) of Lebanese pediatricians in relation to supporting BF. Methods A national survey of Lebanese pediatricians was conducted through Lime Survey (n = 100, response rate 9.5%). The list of pediatricians' emails was obtained from the Lebanese Order of Physicians (LOP). Participants completed a questionnaire covering, in addition to sociodemographic characteristics, the KAP, related to supporting BF. Descriptive statistics and logistic regressions were used in data analysis. Results The most prevalent gaps in knowledge were related to the positioning of the baby during BF (71.9%) and the association between the mother's fluid intake and her milk production (67.4%). With regards to attitudes, 34% of participants reported unfavorable attitudes towards BF in public and BF while working (25%). As for practices, more than 40% of pediatricians kept formula samples and 21% had formula-related advertising in their clinics. Half of the pediatricians reported rarely/never referring mothers to lactation consultants. After adjustment, both being a female pediatrician and having done the residency in Lebanon were significant predictors of better knowledge (OR = 4.51 (95%CI: 1.72-11.85) and OR = 3.93 (95%CI: 1.38,11.19) respectively. Conclusion This study revealed important gaps in the KAP related to BF support among Lebanese pediatricians. Coordinated efforts ought to be exerted to educate and equip pediatricians with needed knowledge and skills to support BF. Copyright: © 2023 Al Rifai et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Preferences for the sequencing of first-line systemic treatments in metastatic hormone receptor-positive, HER2-negative breast cancer
Get PDFIntroduction: Metastatic breast cancer (MBC) is a diverse disease. Therapeutic options include hormonal therapy, chemotherapy, and targeted therapies. The optimal treatment sequence for patients with hormone receptor-positive (HR-positive), HER2-negative metastatic breast cancer remains unknown. Methods: This was a retrospective and prospective study. The data was collected from the medical records of patients in a tertiary healthcare center in Lebanon between the years 2016 and 2019, and patients were followed up for a 3-year duration. The main aim was to identify oncologists’ preferences in the choice and sequence of treatment for newly diagnosed and/or recurrent cases of HR-positive, HER2-negative MBC. Results: A total of 51 patients were included. 24 patients received chemotherapy, while 27 received endocrine therapy as first-line treatment after a diagnosis of MBC, with a median overall survival (OS) of 13 months and a median progression-free survival (PFS) of 12 months after first-line treatment with chemotherapy, compared to 27 months and 18 months with endocrine therapy. A higher percentage of patients have received chemotherapy in the first-line setting compared to the data reported in the literature, with the choice being multifactorial. Conclusion: Factors to consider in MBC management include the choice of first-line treatment, the optimal sequence of treatment, and the combination of available treatment options. Copyright © 2023 Al Mahmasani, Amhaz, Abou Zeidane, Chamseddine, Hatab, Sabbagh, Charafeddine and Assi
Measurement of Work-Life Balance: A Scoping Review with a Focus on the Health Sector
Get PDFBackground. There is an agreement on the importance of measuring work-life balance, especially after the COVID-19 pandemic. However, the available tools to do so are not sufficient to address all dimensions, contexts, and professions. Aim. The article reviews existing instruments that have been widely utilised to tap into the breadth and depth of work-life balance. Evaluation. This is a perspective scoping review guided by PRISMA-ScR guidelines. Articles reporting on the measurement of work-life balance were reviewed. The authors performed the review based on agreed-upon search terms, inclusion and exclusion criteria, search databases, and the data extraction process. Key Issues. The existing tools appear to have divergent underpinning theoretical models, factors, structural/psychometric properties, and the number of accumulated citations. The existing tools also varied in terms of their target sector, with limited tools available for the analysis of work-life balance among healthcare professionals. We argue that while the existing tools provide a general base for the work-life balance measurement, it would be imperative to adjust those tools to the specific cultural and professional contexts. Future work-life balance measures should consider the changes imposed by atypical or disruptive events that have the potential to alter work-life balance, such as in the case of the COVID-19 pandemic. The onus is on researchers and policymakers to work collaboratively in each context to adapt, implement, and evaluate those tools as they become integrated into the matrix of labour market assessments in the future. Conclusions. The article highlighted current gaps and improvement opportunities in the work-life balance measurement field. Implications for Healthcare and Nursing Management. The maintenance of work-life balance will remain an issue for years to come. Ensuring comprehensive and context-specific measurements would be essential to guide the evidence-based recommendations necessary to support the workforce across the various sectors of the economy in the future. © 2023 Mohamad Alameddine et al
Successful separation of pygopagus conjoined twins: A case report
Get PDFIntroduction: Twins conjoined at the sacrum present a complex anatomy that requires the highest levels of medical and surgical care. We present the successful management and separation of pygopagus babies in a tertiary care center. Case presentation: The conjoined female twins were diagnosed by routine prenatal ultrasonography (US) and magnetic resonance (MR) imaging and were delivered uneventfully at 37 weeks of gestation. Postnatal imaging included US of the brain and urinary system, contrast enema, intravenous (IV) contrast-enhanced computed tomography (CT), and MR of the pelvis, which confirmed the sacral and pelvic-perineal organ fusion as well as brain abnormalities in twin B. For the separation, appropriate allocation of the intrapelvic muscles was guided by preoperative and intraoperative sphincter muscle mapping. Baby A received a repaired sphincter with a natural anus, while a functional neo-anus was created for the other baby. Mild superficial wound dehiscence occurred in both twins, which resolved conservatively in twin B and by temporary colostomy diversion in twin A A. Twin B underwent placement of a gastrostomy and a tracheostomy and remains hospitalized. Conclusion: Careful preoperative planning can lead to the successful separation of pygopagus conjoined twins, even in places with limited resources. © 2023 The Author