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Abstract Background The objective of this paper was to estimate the impact of country-wide hospital pay-for-performance on readmissions for a set of common conditions in Lebanon. Methods This retrospective cohort study included all hospitalizations under the coverage of the Ministry of Public Health in Lebanon between 2011 and 2019. We calculated 30-day all-cause readmissions following general, pneumonia, cholecystectomy and stroke cases. We used an interrupted time series design, including the use of AutoRegressive Integrated Moving Average models. This nationwide study including 1,333,691 hospitalizations was undertaken in Lebanon, using hospitalizations at about 140 private and public hospitals contracted by the Ministry. The participants included citizens across all ages under the Ministry’s coverage (52% of citizens). The intervention was the engagement of hospital leaders by the Ministry, informing them of the addition of a readmissions component to the ongoing pay-for-performance initiative. Engagement participants included hospital directors and managers, and the leadership of the Syndicate of Private Hospitals. The main outcome measure was age-adjusted monthly all-cause readmission rates for each of general, pneumonia, cholecystectomy and stroke cases. We also assessed for change in readmissions for three conditions not included in the intervention (myocardial infarction, cataract surgery and appendectomy). Results Across 2011–2019, the overall readmission rates were 6.00% (SD 0.24%) for general readmissions, 5.06% (SD 0.22%) for pneumonia, 2.54% (SD 0.16%) for cholecystectomy, and 6.55% (SD 0.25%) for stroke. Using ARIMA models we found a relative percentage decrease in mean monthly readmissions in the post-intervention period for cholecystectomy (5.9%; CI 0.1%-11.8%) and stroke (13.6%; CI 3.1%-24.2%). There was no evidence of intervention impact on pneumonia and general readmissions, both overall and among small, medium and large hospitals. There was also no evidence of change in non-P4P readmissions of myocardial infarction, cataract surgery and appendectomy. Conclusions Including readmissions within pay-for-performance has the potential to improve hospital performance and patient outcomes, even in countries with more limited resources. Effects may vary across conditions, indicating the need for careful design and understanding of the particular context, both with respect to implementation and to evaluation of impact.

Abstract Introduction The renin–angiotensin–aldosterone system (RAAS) plays a pivotal role in regulating blood pressure (BP), with dysregulation of RAAS resulting in hypertension and potentially heart failure (HF), myocardial infarction (MI), cardio-renal syndrome, and stroke. RAAS inhibitors, such as angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs), have advantages beyond BP control. However, differences between these two drug classes need to be considered when choosing a therapy for preventing cardiovascular events. Methods A panel of 36 Egyptian cardiologists developed consensus statements on RAAS inhibitors for primary and secondary prevention of cardiovascular outcomes and stroke, using a modified three-step Delphi process. Results The consensus statements highlight the importance of effective BP control and the role of RAAS blockade for prevention and management of various cardiovascular diseases. ACEis and ARBs differ in their mode of action and, thus, clinical effects. On the basis of available evidence, the consensus group recommended the following: ACEis should be considered as first choice (in preference to ARBs) to reduce the risk of MI, for primary prevention of HF, and for secondary prevention of stroke. ACEis and ARBs show equivalent efficacy for the primary prevention of stroke. Evidence also favors the preferential use of ACEis in patients with type 2 diabetes, for BP control, for the primary prevention of diabetic kidney disease, and to reduce the risk of major cardiovascular and renal outcomes. Treatment with an ACEi should be started within 24 h of ST segment elevation MI (and continued long term) in patients with HF, left ventricular systolic dysfunction, and/or diabetes. Angiotensin receptor/neprilysin inhibitors (ARNIs) are the first choice for patients with HF and reduced ejection fraction, with ACEis being the second choice in this group. ARBs are indicated as alternatives in patients who cannot tolerate ACEis. ACEis may be associated with cough development, but the incidence tends to be overestimated, and the risk can be reduced by use of a lipophilic ACEi or combining the ACEi with a calcium channel blocker. Conclusion RAAS blockade is an essential component of hypertension therapy; however, the protective effects provided by ACEis are superior to those of ARBs. Therefore, an ACEi is indicated in almost all cases, unless not tolerated.

Abstract Background Cardiogenic shock (CS) remains a major cause of morbidity and mortality, particularly in developing countries where there are limited resources and a lack of data on CS outcomes. This study aimed to investigate 30-day all-cause mortality in Egyptian patients with CS at tertiary referral centers. Results This prospective, observational multicenter registry analyzed 16,681 patients from six cardiac centers, to evaluate the incidence, causes and predictors of CS-related mortality. Among the 529 diagnosed CS patients, 68.2% had an ischemic etiology. No discernable variations were observed in clinical or laboratory features, as well as mortality rates, between ischemic and non-ischemic CS patients. Within 30 days, 210 deaths (39.7%) occurred. Non-survivors with ischemic CS had a higher prevalence of diabetes, worsening renal function, and were more likely to receive multiple inotropes. Mortality did not significantly differ between acute coronary syndrome patients with ST elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) (42.7% vs. 43.7%, p

BackgroundPatient perspectives have received increasing importance within health systems over the past four decades. Measures of patient experience and satisfaction are commonly used. However, these measures do not capture all the information that is available through engaging with patients. An improved understanding of the various types of patient perspectives and the distinctions between them is needed. The lack of such knowledge limits the usefulness of including patient perspectives as components within pay-for-performance initiatives. This study aimed to explore patient perspectives on hospital care in Lebanon. It also aimed to contribute insights that may improve the national pay-for-performance initiative and to the knowledge on engaging patients towards person-centered health systems.MethodsWe conducted a qualitative study using focus group discussions with persons recently discharged after hospitalization under the coverage of the Lebanese Ministry of Public Health. This study was implemented in 2017 and involved 42 participants across eight focus groups. Qualitative content analysis was used to analyze the information provided by participants.ResultsFive overall themes supported by 17 categories were identified, capturing the meaning of the participants' perspectives: health is everything; being turned into second class citizens; money and personal connections make all the difference; wanting to be treated with dignity and respect; and tolerating letdown, for the sake of right treatment. The most frequently prioritized statement in a ranking exercise regarding patient satisfaction was regular contact with the patient's doctor.ConclusionsPatient perspectives include more than what is traditionally incorporated in measures of patient satisfaction and experience. Patient valuing of health and their perceptions on each of the health system, and access and quality of care should also be taken into account. Hospital pay-for-performance initiatives can be made more responsive through a broader consideration of these perspectives. More broadly, health systems would benefit from wider engagement of patients. We propose a framework relating patient perspectives to value-based healthcare and health system performance.

Glomerulonephritis (GN) is rare kidney disease that often requires treatment with immunosuppressive drugs. The choice of therapy usually relies on international guidelines. There are no data so far regarding the treatment of glomerular diseases in the eastern Mediterranean region. This study aimed to describe the most frequently treated glomerular diseases among the Lebanese population. This is a retrospective study that reviewed all patients’ medication coverage claims, presented at the Lebanese Ministry of Public Health between 2014 and 2015. All patients that had kidney biopsies in their charts were included. A total of 144 patients were included: 35 children and 109 adults. Half of the children had minimal change disease treated with mycophenolate mofetil (MMF). In adults, 33% had lupus nephritis (LN) with a male to female ratio 12/24, 28.4% focal segmental glomerulosclerosis (FSGS), 14.6% membranous nephropathy (MN), and 24% other types. There was a significant difference in age among different GN (P = 0.01). MMF was the most commonly used drug in adults: 88.8% of LN cases, 51.6% in FSGS, 18.7% in MN, and 100% in immunoglobulin A nephropathy. This study showed that LN is the most frequently treated GN in Lebanon and was managed according to guidelines. MMF use was prevailing even in cases not suggested by the Kidney Disease Improving Global Outcomes. Further studies are needed to see whether these results apply to other countries.

Abstract Aims Worsening of renal function (WRF) is a common complication in patients with acute decompensated heart failure (ADHF). We aimed to evaluate the role of intrarenal Doppler ultrasound (IRD) in the early prediction of WRF in this patient group. Methods and results Among 90 patients (age: 57.5 ± 11.1 years; 62% male) hospitalized with ADHF, resistivity index (RI), acceleration time (AT), and pulsatility index (PI) were measured on admission and at 24 and 72 h. WRF was defined as increased serum creatinine ≥0.3 mg/dL from baseline. Adverse clinical outcomes were defined as the composite of death, use of vasopressors, and need for ultrafiltration for refractory oedema. WRF developed in 40% of patients. Mean values of renal AT, RI, and PI on admission were 59.7 ± 15, 0.717 ± 0.08, and 1.5 ± 0.48 ms, respectively. At 24 h, there was significant decrease in AT (to 56.7 ± 10 ms, P = 0.02) and renal RI (to 0.732 ± 0.07; P

Abstract Background In the international agenda, it has become common to assert that the assessment of health system governance using a practical tool is crucial. This approach can help us better understand how health systems are being steered as well as to identify gaps in the decision-making process and their causes. The authors developed a new assessment tool, the Health Policymaking Governance Guidance Tool (HP-GGT), that was designed to be conceptually sound and practical. This tool enables policy-makers and stakeholders to systematically review and assess health system governance at policy-making level. This article presents first use of the HP-GGT in Lebanon, together with generated results, recommendations, and discusses how these results improve governance practices when initiating new health policy formulation processes. Methods The HP-GGT, which is a multidimensional structured tool, was used retrospectively to assess and review the process used to develop a new mental health strategy; this process was compared against consensus-based good governance principles, focusing on participation, transparency, accountability, information and responsiveness. The assessment was conducted through face-to-face interviews with 11 key informants who were involved in the development of the strategy. Results The HP-GGT enabled policy-makers to reflect on their governance practices when developing a mental health strategy and was able to identify key areas of strengths and weaknesses using good governance practice checklists given by the questions. The insights generated from the assessment equipped the national policy-makers with a better understanding of the practice and meaning of policy-making governance. Identifying weaknesses to be addressed in future attempts to develop other national health policies helped in this regard. Using the tool also increased awareness of alternative good practices among policy-makers and stakeholders. Conclusions Assessing a health policy formulation process from a governance perspective is essential for improved policy-making. The HP-GGT was able to provide a general overview and an in-depth assessment of a policy formulation process related to governance issues according to international good practices that should be applied while formulating health policies in any field. The HP-GGT was found to be a practical tool that was useful for policy-makers when used in Lebanon and awaits applications in other low- and middle-income countries to further show its validity and utility.

# Background The war in Syria triggered the influx of a large number of refugees into neighboring countries, particularly Lebanon. In 2019, the Syrian population made up 13.33% of the total population in Lebanon. This shift in demographics influenced many sectors in the country, including the healthcare system. The purpose of this study is to analyze the impact of Syrian refugees on the Lebanese healthcare system across five public health centers (PHCs) and the prevalence of type II diabetes (T2D) in these patients. # Methods Patient data was collected across five PHCs from different regions in Lebanon. Comparisons between Lebanese and Syrian patients were analyzed for demographics, relative number of patients, and prevalence of T2D. # Results We found that the number of patients admitted to PHCs has increased over the last few years, in both Syrian and Lebanese populations, putting more strains on an already threatened sector. In addition, the increase in Lebanese patients is significantly higher after 2015, and it parallels the surge in Syrian immigrants. The prevalence of T2D was found to be increasing over the years among the two populations, with a statistically significant increase in the Lebanese population after 2015. However, the prevalence of T2D was found to be statistically lower than the reported national prevalence in both groups, possibly due to inadequate rates of screening. # Conclusions There has been an increase in admissions to PHCs as well as rates of T2D in Lebanon and in the Syrian population. Inadequate screening could be the reason behind the lower prevalence of T2D in our study compared to the reported national prevalence.

PURPOSE: Chronic myeloid leukemia (CML) ranks second in terms of disease-related health care expenditures at the Lebanese Ministry of Public Health (MoPH) after breast cancer. With the introduction of tyrosine kinase inhibitors (TKIs), survival of patients with CML has dramatically improved and approached that of the normal population. In recent years, several studies demonstrated that patients who achieve a deep molecular response while receiving TKI therapy could safely attempt treatment-free remission (TFR), the new treatment goal in patients with CML. The objective is to estimate the budget impact of TFR at the MoPH. METHODS: Analyses were done on 162 patients with CML receiving imatinib, nilotinib, or dasatinib, as first-line or second-line therapy, over a 4-year time horizon using MoPH drug pricing. The model assumed that patients could attempt TFR after 36 months of TKI therapy, where the last 24 months were at stable molecular response as per MoPH and National Comprehensive Cancer Network guidelines. Duration of TFR was based on European Stop Kinase Inhibitor treatment-free survival curve. RESULTS: Out of the 162 patients, 83 were eligible to attempt TFR, 36 patients were not eligible, 32 patients were lost to follow-up, two patients died as a result of CML progression, and five died as a result of other causes. The total cost of CML treatment with TFR from the time of analysis and over 4 years can be reduced by more than 7 million US dollars (57%). CONCLUSION: The model can be used to inform health care decision makers on the importance of TFR and the potential savings.

Background: In 2014 the Lebanese Ministry of Public Health integrated pay-for-performance into setting hospital reimbursement tiers, to provide hospitalization service coverage for the majority of the Lebanese population. This policy was intended to improve effectiveness by decreasing unnecessary hospitalizations, and improve fairness by including risk-adjustment in setting hospital performance scores. Methods: We applied a systematic approach to assess the impact of the new policy on hospital performance. The main impact measure was a national casemix index, calculated across 2011-2016 using medical discharge and surgical procedure codes. A single-group interrupted time series analysis model with Newey ordinary least squares regression was estimated, including adjustment for seasonality, and stratified by case type. Code-level analysis was used to attribute and explain changes in casemix index due to specific diagnoses and procedures. Results: Our final model included 1,353,025 cases across 146 hospitals with a post-intervention lag-time of two months and seasonality adjustment. Among medical cases the intervention resulted in a positive casemix index trend of 0.11% per month (coefficient 0.002, CI 0.001-0.003), and a level increase of 2.25% (coefficient 0.022, CI 0.005-0.039). Trend changes were attributed to decreased cases of diarrhea and gastroenteritis, abdominal and pelvic pain, essential hypertension and fever of unknown origin. A shift from medium to short-stay cases for specific diagnoses was also detected. Level changes were attributed to improved coding practices, particularly for breast cancer, leukemia and chemotherapy. No impact on surgical casemix index was found. Conclusions: The 2014 policy resulted in increased healthcare effectiveness, by increasing the casemix index of hospitals contracted by the Ministry. This increase was mainly attributed to decreased unnecessary hospitalizations and was accompanied by improved medical discharge coding practices. Integration of pay-for-performance within a healthcare system may contribute to improving effectiveness. Effective hospital regulation can be achieved through systematic collection and analysis of routine data.

Abstract Background Following the Syrian crisis, a substantial influx of Syrian refugees into Lebanon posed new challenges to optimal vaccination coverage for all children residing in the country. In 2016, the district-based immunization coverage evaluation survey (CES) assessed routine immunization coverage at the district level in Lebanon among children aged 12–59 months. Methods A cross-sectional multistage cluster survey was conducted in all of Lebanon (with the exception of the Nabatieh district) using the World Health Organization (WHO) recommended Expanded Programme on Immunization (EPI) methodology adapted to the local context. A survey questionnaire consisting of closed and open-ended questions concerning demographic information and the child’s immunization status was administered to collect immunization status information. Results Among surveyed children aged 12–59 months, irrespective of nationality, vaccination coverage at the national level for any recommended last dose was below the targeted 95%. Generally, vaccination coverage levels increased with age and were higher among Lebanese than Syrian children. However, large variations were revealed when coverage rates were analyzed at the district level. Vaccination was significantly associated with nationality, age, mother’s educational status and the place of vaccination. Common reasons for undervaccination included the child’s illness at the time of vaccine administration, vaccination fees, lack of awareness or a doctor’s advice not to vaccinate during campaigns. Conclusions Substantial variability exists in vaccination coverage among children aged 12–59 months residing in different districts in Lebanon. Immunization coverage reached 90% or above only for the first doses of polio and pentavalent vaccines. A considerable dropout rate from the first dose of any vaccine is observed. Efforts to optimize coverage levels should include increased vaccination initiatives targeting both refugee children and children from vulnerable host communities, increased cooperation between public and private vaccine providers, improved training for vaccine providers to adhere to complete vaccine administration recommendations, and increased awareness among caregivers.

Purpose: This study aims to evaluate trends in the increasing costs of oncology drugs procured by the Lebanese Ministry of Public Health (MOPH) between 2014 and 2016 and to assess the impact of the introduction in mid-2015 of new immunotherapy drugs for the treatment of lung cancer on the overall and specific costs of that treatment. Methods: A secondary analysis of data from the MOPH Cancer Drug Scientific Committee data base was conducted using a total of 18,133 cancer files between 2014 and 2016. Results: Over the 3-year period, about $140 million (USD) was spent on cancer drugs by the MOPH free cancer drug dispensing program. The expenditures increased by 27% after immunotherapy was phased in. The average cost of drugs per patient per year measured across all cancer types increased from $7,000 in 2014 to $8,400 in 2016. Trastuzumab, approved for treating human epidermal growth factor receptor 2–positive breast cancer ranked first in total expenditures for 2014-2015. By 2016, two new immunotherapy drugs had topped the list: pembrolizumab ranked first and nivolumab ranked third, representing 64% of the total cost of lung cancer treatment and approximately 19% of the total yearly budget; beneficiaries represented only 3% of all patients. Conclusion: This update documents the increasing financial impact of newer cancer drugs on the procurement process in the middle-income country of Lebanon. The trend is aligned with the financial burden of cancer drugs worldwide, which calls for a collaborative global response to this crisis.

Abstract—Since 2009, the Ministry of Public Health (MoPH) in Lebanon has been going through a major reform initiative to improve its contracting system with private and public hospitals. The private sector is the main provider of hospital care in the country and the main contractor to the MoPH for the provision of curative care. As an “insurer of last resort,” the MoPH plays an important role in providing hospital coverage to 53% of the population who lack coverage by private or public insurance schemes, through contractual arrangements with the private sector. Historically, the MoPH used hospital accreditation as the basis for contracting and for determining the reimbursement rate. However, recent studies by the MoPH showed that reimbursing hospitals solely on accreditation results was not appropriate and led to an unfair and inefficient reimbursement system. The reform program included the development of several components, in particular, an automated billing system, a utilization review function, standardized admission criteria, and a hospital case mix index that accounts for case complexity. In 2014, the MoPH started implementing a new mixed-model contracting system with private and public hospitals. Preliminary evaluation of the new model suggests that the system incentivized hospitals to admit fewer inappropriate cases and more cases that are more complex/serious. This article shares one experience of how to introduce a merit-based system to face the common practice of political clientelism and confessional/religious-based favoritism in Lebanon. It highlights the importance of stakeholder engagement in a framework of networking and participatory governance that proved to be a key element behind the resilience of a diversified health system.

A preparedness plan for avian influenza A(H5N1) virus infection was activated in Lebanon in 2016 after reported cases in poultry. Exposed persons were given prophylaxis and monitored daily. A total of 185 exposed persons were identified: 180 received prophylaxis, 181 were monitored, and 41 suspected cases were reported. All collected specimens were negative for virus by PCR.

The Lebanese Ministry of Public Health has launched a National Mental Health Programme, which in turn has established the Mental Health and Substance Use Strategy for Lebanon 2015–2020. In parallel, research involving refugees has been conducted since the onset of the Syrian crisis. The findings point to an increase in mental health disorders in the Syrian refugee population, which now numbers more than 1 million.

In non-dialysis chronic kidney disease patients, looking for iron deficiency is highly variable in practice and there is a great variability regarding the cutoffs used to treat iron deficiency. The aim of this study is to investigate the degree of iron deficiency in non-dialysis chronic kidney disease patients on erythropoiesis-stimulating agents. We included all non-dialysis chronic kidney disease patients that applied to the Lebanese Ministry of Public Health for erythropoiesis-stimulating agents' coverage during a 5-month period. Iron requirement was assessed based on two guidelines' target-to-treat cutoffs: 1-ferritin

In Lebanon, hepatitis C virus (HCV) prevalence is estimated to 0.2% among all ages, with genotype 1 the most common genotype. The age distribution shows 2 peaks reflecting 2 probable mode of transmission of HCV in Lebanon: 20-39 years and more than 40 years. The burden of HCV-related complications on the health system in Lebanon is expected to increase in the upcoming years. The number and prevalence per age group and the fibrosis stage of HCV infections is required to better estimate the burden of the disease in Lebanon. We calculated the prevalence per age group. Concerning fibrosis stage, patients recently diagnosed with HCV and never been treated previously were included and were divided into three groups according to their age Concerning the prevalence by age group, the lowest was seen in the group less than 20 years and the highest in the population aged more than 60. Concerning the fibrosis by age group, the majority of patients less than 40 years had low fibrosis stage, while in the group of more than 60 years F3 and F4 represent respectively 15.07% and 68.49%. Female gender had more significant fibrosis and cirrhosis than male gender. There is an exponential increase of significant fibrosis with age In Lebanon, the highest prevalence of hepatitis C is seen in the age group more than 60 years. In the 2 age groups (40-59 years and >60 years), we noted an advanced fibrosis stage and the majority of patient more than 60 years were cirrhotic at the time of diagnosis, which can reflect the burden of the disease in these groups.

Background: Infective endocarditis (IE) is associated with substantial morbidity and mortality. However, there are conflicting views as to the significance of bacteremia caused by interventional procedures in the existing clinical guidelines. Objectives: Formal evaluation of risk factors for IE is lacking in Egyptian tertiary care centers. We test the hypothesis that underlying medical conditions, not culprit procedures, are the most important risk factor for development of IE. Methods: We matched 175 patients with definite IE from IE database of the Cardiology Department, Cairo University Hospital with175 control cases without IE, matched for age, sex, and underlying heart disease. Demographic and clinical data, comorbidities and potential culprit procedures during the 3 months prior to the diagnosis of IE were recorded. Results: Host-related risk factors included renal impairment (p

Background: The eastern Mediterranean region is comprised of 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen. Since our Global Burden of Disease Study 2010 (GBD 2010), the region has faced unrest as a result of revolutions, wars, and the so-called Arab uprisings. The objective of this study was to present the burden of diseases, injuries, and risk factors in the eastern Mediterranean region as of 2013. Methods: GBD 2013 includes an annual assessment covering 188 countries from 1990 to 2013. The study covers 306 diseases and injuries, 1233 sequelae, and 79 risk factors. Our GBD 2013 analyses included the addition of new data through updated systematic reviews and through the contribution of unpublished data sources from collaborators, an updated version of modelling software, and several improvements in our methods. In this systematic analysis, we use data from GBD 2013 to analyse the burden of disease and injuries in the eastern Mediterranean region specifically. Findings: The leading cause of death in the region in 2013 was ischaemic heart disease (90·3 deaths per 100 000 people), which increased by 17·2% since 1990. However, diarrhoeal diseases were the leading cause of death in Somalia (186·7 deaths per 100 000 people) in 2013, which decreased by 26·9% since 1990. The leading cause of disability-adjusted life-years (DALYs) was ischaemic heart disease for males and lower respiratory infection for females. High blood pressure was the leading risk factor for DALYs in 2013, with an increase of 83·3% since 1990. Risk factors for DALYs varied by country. In low-income countries, childhood wasting was the leading cause of DALYs in Afghanistan, Somalia, and Yemen, whereas unsafe sex was the leading cause in Djibouti. Non-communicable risk factors were the leading cause of DALYs in high-income and middle-income countries in the region. DALY risk factors varied by age, with child and maternal malnutrition affecting the younger age groups (aged 28 days to 4 years), whereas high bodyweight and systolic blood pressure affected older people (aged 60–80 years). The proportion of DALYs attributed to high body-mass index increased from 3·7% to 7·5% between 1990 and 2013. Burden of mental health problems and drug use increased. Most increases in DALYs, especially from non-communicable diseases, were due to population growth. The crises in Egypt, Yemen, Libya, and Syria have resulted in a reduction in life expectancy; life expectancy in Syria would have been 5 years higher than that recorded for females and 6 years higher for males had the crisis not occurred. Interpretation: Our study shows that the eastern Mediterranean region is going through a crucial health phase. The Arab uprisings and the wars that followed, coupled with ageing and population growth, will have a major impact on the region's health and resources. The region has historically seen improvements in life expectancy and other health indicators, even under stress. However, the current situation will cause deteriorating health conditions for many countries and for many years and will have an impact on the region and the rest of the world. Based on our findings, we call for increased investment in health in the region in addition to reducing the conflicts. Funding: Bill & Melinda Gates Foundation.

Hemorrhagic complications have been strongly linked with subsequent morbidity and mortality in patients with acute coronary syndromes (ACS). Objectives: To determine the incidence and predictors of major bleeding and its impact on outcomes, including mortality, in patients with ACSs. Methods: Patients (n_ 200) with ACS, clinical data, management strategies, complications and outcome were reported in case report form. Factors associated with major bleeding were identified using logistic regression analysis and impact of major bleeding on outcomes, including mortality was reported. Results: Bleeding occurred in 41 pts (20.5%), and was classified as nuisance (15 pts, 7.5%), minor (21pts, 10.5%) and major bleeding (5pts, 2.5%). Advanced age (p = 0.02), interventional coronary procedures (p = 0.001), low BMI (p = 0.047), Clopidogrel loading > 300 mg (p = 0.006) and renal insufficiency (p = 0.04) were independently associated with a higher risk of major bleeding. Bleeding was independently associated with an increased risk of hospital and 30 day incidence of death, MI and stroke (p = 0.03). Patients with major bleeding showed higher frequency of blood transfusion (p = 0.0001), discontinuation of antithrombotics (p = 0.0001), mortality (p = 0.0001), and MI (p = 0.02). Haemoglobin decrease at cut off point of 3.4 gm predicted major complications with sensitivity 91% and specificity 88% with AUC of 0.9 and (p = 0.0001). Conclusions: Major bleeding is a powerful independent predictor of in-hospital and 30 day mortality in patients with ACS. Advanced age, renal insufficiency, high clopidogrel loading and invasive coronary procedures are independent risk factors for major bleeding in ACS patients.

Infective endocarditis (IE) is associated with substantial morbidity and mortality. The numbers of patients with chronic predisposing medical comorbidities have increased as has the commensurate risk of exposure to nosocomial bacteremia. However, there are conflicting views as to the significance of bacteremia caused by interventional procedures in the existing IE clinical guidelines. Aim of the work: Many IE risk factors have been postulated, but formal evaluation of these risk factors is lacking in Egyptian tertiary care Centers. In this study, we test the hypothesis that underlying medical conditions, not culprit procedures, are the most important risk factor for development of IE in an Egyptian tertiary care center. Patients and methods: We matched 175 patients with definite IE from the IE database of Cardiology Department at Cairo University Hospital with175 control cases without IE, matched for age, sex, and underlying heart disease.Demographic and clinical data, comorbidities and potential culprit procedures during the 3 months prior to the diagnosis of IE were recorded in both groups. Continuous and categorical variables were compared using a two-tailed t-test and Pearson’s chi-square analysis, respectively. Correlations were tested using Pearsosn’s correlation coefficient. Results: Host-related risk factors included renal impairment (12% vs. 1.1%, p

Cardiac adverse effects influenced by diabetes have been demonstrated thus far for the left ventricle. Right ventricular dysfunction is relevant in a variety of disease states affecting both the course and prognosis. Therefore assessment of right ventricular performance is also an important issue in diabetic patients. Aim of the work: To study right ventricular systolic and diastolic functions using conventional and tissue Doppler echocardiographic imaging in asymptomatic type 2 diabetic patients and to assess the relationship of RV functions to diabetes severity and complications. Patients and methods: Fifty patients with type 2 diabetes with no cardiac diseases were prospectively enrolled. The control group included fifteen healthy volunteers. Patients with hypertension, valvular or coronary heart disease were excluded. Full clinical evaluation including fundus examination, laboratory work up including (FBS, HbA1C, hs-CRP, S. creatinine and albuminuria), 12 lead ECG and full conventional and tissue Doppler echocardiographic assessment of both ventricles. Results: Right ventricular diastolic function was abnormal in diabetic group as evidenced by significantly lower values of peak early diastolic velocity Em (p