Hani Dimassi

Evaluating the degree of difficulty of laparoscopic colorectal surgery

OBJECTIVE To quantify the degree of overall difficulty and the difficulty of each of the individual steps involved in the performance of laparoscopic colorectal procedures. The data should serve as a guide to surgeons in the early stages of their experience in laparoscopic colorectal surgery as to which procedures and steps to embark on first, to allow them to build experience in a stepwise fashion. METHODS A mail-in survey of 35 experienced laparoscopic colorectal surgeons was conducted. Using a scale of 1 to 6, the surgeons were asked to rate the overall degree of difficulty of each of 12 laparoscopic colorectal procedures. Each procedure was then broken down into its key components (exposure, isolation of the vascular pedicle, dissection of the specimen, and anastomosis), and the raters were asked to individually grade each of these components for each intervention. An overall difficulty score was created for each procedure, as well as an individual difficulty score for each step. RESULTS The response rate was 80%, representing a collective experience of approximately 6335 laparoscopic colorectal interventions. On the overall difficulty score, sigmoid colectomy achieved the lowest composite score of 2.0, while reversal of the Hartmann procedure scored the highest at 4.5. Analyzing the individual step complexity rating, mobilization of the splenic flexure scored highest, ahead of rectal mobilization. Vascular dissection scored significantly higher for right colectomy than for sigmoid resection, as did intracorporeal vs extracorporeal anastomosis for right colectomy. CONCLUSIONS The learning curve for laparoscopic colorectal surgery is steep. This survey can help surgeons in the early part of this curve in their initial choice of procedure and allow them to build experience in a stepwise manner. This will help to identify achievable goals and develop strategies for reducing operating times and improving patient outcome by selecting appropriate cases at the outset.

Lifetime Prevalence of Mental Disorders in Lebanon: First Onset, Treatment, and Exposure to War

Background There are no published data on national lifetime prevalence and treatment of mental disorders in the Arab region. Furthermore, the effect of war on first onset of disorders has not been addressed previously on a national level, especially in the Arab region. Thus, the current study aims at investigating the lifetime prevalence, treatment, age of onset of mental disorders, and their relationship to war in Lebanon. Methods and Findings The Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation study was carried out on a nationally representative sample of the Lebanese population (n = 2,857 adults). Respondents were interviewed using the fully structured WHO Composite International Diagnostic Interview 3.0. Lifetime prevalence of any Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) disorder was 25.8%. Anxiety (16.7%) and mood (12.6%) were more common than impulse control (4.4%) and substance (2.2%) disorders. Only a minority of people with any mental disorder ever received professional treatment, with substantial delays (6 to 28 y) between the onset of disorders and onset of treatment. War exposure increased the risk of first onset of anxiety (odds ratio [OR] 5.92, 95% confidence interval [CI] 2.5–14.1), mood (OR 3.32, 95% CI 2.0–5.6), and impulse control disorders (OR 12.72, 95% CI 4.5–35.7). Conclusions About one-fourth of the sample (25.8%) met criteria for at least one of the DSM-IV disorders at some point in their lives. There is a substantial unmet need for early identification and treatment. Exposure to war events increases the odds of first onset of mental disorders.

Exposure to War-Related Traumatic Events, Prevalence of PTSD, and General Psychiatric Morbidity in a Civilian Population From Southern Lebanon:

The South of Lebanon has experienced prolonged armed conflict. The current study aims to investigate the degree of exposure to traumatic events and prevalence of posttraumatic stress disorder (PTSD) and nonspecific general psychiatric morbidity in a civilian population from the South of Lebanon. The design was cross-sectional with random sampling. War-related traumatic events and symptoms of PTSD were assessed by the Harvard Trauma Questionnaire and general psychiatric morbidity by the General Health Questionnaire (GHQ-28). Almost all participants, 97.7%, had experienced, witnessed, or heard of a war-related traumatic event. Current PTSD prevalence was 29.3%. PTSD symptoms correlated highly with GHQ-28 symptoms, r = .73 (p < .0001). The present study indicates a need for psychological interventions in the population and studies to assess such interventions.

Occupational Violence at Lebanese Emergency Departments: Prevalence, Characteristics and Associated Factors

Occupational Violence at Lebanese Emergency Departments: Prevalence, Characteristics and Associated Factors: Mohamad Alameddine, et al. Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Lebanon—

Ratio Between Positive Lymph Nodes and Total Excised Axillary Lymph Nodes as an Independent Prognostic Factor for Overall Survival in Patients with Nonmetastatic Lymph Node-Positive Breast Cancer

Background.The status of the axillary lymph nodes in nonmetastatic lymph node-positive breast cancer (BC) patients remains the single most important determinant of overall survival (OS). Although the absolute number of nodes involved with cancer is important for prognosis, the role of the total number of excised nodes has received less emphasis. Thus, several studies have focused on the utility of the axillary lymph node ratio (ALNR) as an independent prognostic indicator of OS. However, most studies suffered from shortcomings, such as including patients who received neoadjuvant therapy or failing to consider the use of adjuvant therapy and tumor receptor status in their analysis.Methods.We conducted a single-center retrospective review of 669 patients with nonmetastatic lymph nodepositive BC. Data collected included patient demographics; breast cancer risk factors; tumor size, histopathological, receptor, and lymph node status; and treatment modalities used. Patients were subdivided into four groups according to ALNR value (<.25, .25–.49, .50–.74, .75–1.00). Study parameters were compared at the univariate and multivariate levels for their effect on OS.Results.On univariate analysis, both the absolute number of positive lymph nodes and the ALNR were significant predictors of OS. On multivariate analysis, only the ALNR remained an independent predictor of OS, with a 2.5-fold increased risk of dying at an ALNR of ≥.25.Conclusions.Our study demonstrates that ALNR is a stronger factor in predicting OS than the absolute number of positive axillary lymph nodes.

Characterisation of Pga1, a putative Candida albicans cell wall protein necessary for proper adhesion and biofilm formation.

The fungal pathogen Candida albicans is a leading causative agent of death in immunocompromised individuals. Many factors have been implicated in virulence including filamentation‐inducing transcription factors, adhesins, lipases and proteases. Many of these factors are glycosylphosphatidylinositol‐anchored cell surface antigenic determinant proteins. Pga1 is one such protein shown to be upregulated during cell wall regeneration. The purpose of this study was to characterise the role Pga1 plays by creating a homozygous pga1 null strain and comparing the phenotype with the parental strain. It was observed that the mutant strain showed less oxidative stress tolerance and an increased susceptibility to calcofluor white, a cell surface disrupting agent that inhibits chitin fibre assembly which translated as a 40% decrease in cell wall chitin content. Furthermore, the mutant exhibited a 50% reduction in adhesion and a 33% reduction in biofilm formation compared with the parental strain, which was reflected as a slight reduction in virulence. Our data suggest that Pga1 plays an important role in cell wall rigidity and stability. It was also observed that the pga1 null was over filamentous on both liquid and solid media and exhibited increased resistance to SDS suggesting upregulation of filamentation‐inducing genes and cell surface components to partially compensate for the deletion.

The Candida albicans Hwp2 is necessary for proper adhesion, biofilm formation and oxidative stress tolerance

Candida albicans is an important fungal pathogen of humans that is responsible for the majority of mucosal and systemic candidiasis. The host-pathogen interaction in C. albicans has been the subject of intense investigation as it is the primary step that leads to establishment of infection. Hwp2 is a cell wall GPI-anchored cell wall protein that was previously shown to be necessary for hyphal and invasive growth on solid media. The purpose of the current study is to further characterize the protein as far as its role in oxidative stress, sensitivity to cell wall disrupting agents, adhesion to human epithelial and endothelial cells, biofilm formation and chitin content. It appears that Hwp2 is necessary for proper oxidative stress tolerance, adhesion and biofilm formation as an hwp2 null is more susceptible to increasing doses of hydrogen peroxide, unable to adhere efficiently to epithelial and endothelial cell lines and unable to form wild type biofilm levels.

Outcome of depression and anxiety after war

Prospective studies of children exposed to war have not investigated disorders other than posttraumatic stress disorder (PTSD) and have methodological limitations. From a stratified random sample of 386 children and adolescents who had been interviewed 3 weeks after war exposure (Phase 1) a random subsample (N = 143) was interviewed a year later (Phase 2). PTSD, major depressive disorder (MDD), separation anxiety disorder (SAD), overanxious disorder (OAD), and psychosocial stressors were assessed using structured interviews administered to both children and adolescents and their parents. The prevalence of disorders among the 143 at Phase 1 was MDD 25.9%, SAD 16.1%, OAD 28.0%, and PTSD 26.0%, with 44.1% having any disorder. At Phase 2 the prevalence was MDD, 5.6%; SAD, 4.2%; OAD, 0%; and PTSD, 1.4%, with 9.2% having any disorder. Occurrence of disorders at Phase 1 was associated with older age, prewar disorders, financial problems, fear of being beaten, and witnessing any war event (ORs ranged from 2.5 to 28.6). Persistence of disorders to Phase 2 was associated with prewar disorders (OR = 6.0) and witnessing any war event (OR = 14.3). There are implications for detection of at-risk cases following wars by screening for adolescents exposed to family violence, those with prewar disorders, and those who directly witnessed war events to target them for specific interventions.

Outcome of Depression and Anxiety After War: A Prospective Epidemiologic Study of Children and Adolescents

Prospective studies of children exposed to war have not investigated disorders other than posttraumatic stress disorder (PTSD) and have methodological limitations. From a stratified random sample of 386 children and adolescents who had been interviewed 3 weeks after war exposure (Phase 1) a random subsample (N = 143) was interviewed a year later (Phase 2). PTSD, major depressive disorder (MDD), separation anxiety disorder (SAD), overanxious disorder (OAD), and psychosocial stressors were assessed using structured interviews administered to both children and adolescents and their parents. The prevalence of disorders among the 143 at Phase 1 was MDD 25.9%, SAD 16.1%, OAD 28.0%, and PTSD 26.0%, with 44.1% having any disorder. At Phase 2 the prevalence was MDD, 5.6%; SAD, 4.2%; OAD, 0%; and PTSD, 1.4%, with 9.2% having any disorder. Occurrence of disorders at Phase 1 was associated with older age, prewar disorders, financial problems, fear of being beaten, and witnessing any war event (ORs ranged from 2.5 to 28.6). Persistence of disorders to Phase 2 was associated with prewar disorders (OR = 6.0) and witnessing any war event (OR = 14.3). There are implications for detection of at-risk cases following wars by screening for adolescents exposed to family violence, those with prewar disorders, and those who directly witnessed war events to target them for specific interventions.

A National Study on Nurses' Exposure to Occupational Violence in Lebanon: Prevalence, Consequences and Associated Factors.

Background Healthcare institutions have commonly reported exposure of employees, particularly nurses, to high levels of occupational violence. Despite such evidence in the Middle East Region, there is a dearth of national studies that have systematically investigated this phenomenon. This study investigates the prevalence, characteristics, consequences and factors associated with nurses’ exposure to occupational violence in Lebanon. Methods A cross-sectional design was utilized to survey a nationally representative sample of 915 nurses registered with the Order of Nurses in Lebanon. Stratified random sampling by governorate was utilized. Individually-mailed questionnaires collected information on exposure to violence, degree of burnout and demographic/professional background. The main outcome variables were exposure to verbal abuse (never, 1–3, 4–9 and 10+ times) and physical violence (never, ever) over the past 12-months. Descriptive statistics were used to estimate prevalence of violence. Multivariable, binomial and multinomial regression models were carried out to investigate the correlates of exposure to verbal abuse and physical violence, respectively. Results Response rate was 64.8%. Over the last year, prevalence of nurses’ exposure to verbal abuse was 62%, (CI: 58–65%) and physical violence was 10%, (CI: 8–13%). Among respondents, 31.7% of nurses indicated likelihood to quit their jobs and 22.3% were undetermined. Furthermore, 54.1% reported high levels of emotional exhaustion and 28.8% reported high levels of depersonalization. Compared to nurses with no exposure to verbal abuse, nurses reporting high exposure had high levels of emotional exhaustion (OR:6.4; CI:1.76–23.32), depersonalization (OR:6.8; CI: 3–15) and intention to quit job (OR:3.9; CI: 1.8–8.3). They further reported absence of anti-violence policies at their institutions (OR: 3; CI: 1.5–6.3). Nurses that were ever exposed to physical violence were more likely to be males (OR: 2.2; CI: 1.1–4.3), working day and night shifts (OR: 2.8; CI: 1.4–5.5) and subject to ten or more incidents of verbal abuse per year (OR: 46.7; CI: 10.1–214). Conclusions An alarming two-thirds of respondents reported exposure to verbal abuse which was found to be a significant predictor of the three subscales of burnout, intention to quit and exposure to physical violence. The prevalence of exposure to physical violence is disconcerting due to its severe consequences. Policy and decision-makers are urged to use study findings for policy and practice interventions to create safe work environments conducive to nurses’ productivity and retention.