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Rita Georges Nohra,1– 3 Taghrid Chaaban,1,4 Hala Sacre,3 Pascale Salameh,3,5– 7 Zeina Aoun Bacha,8 Beatrice Le Bon Chami,9 Fadi Abou Rizk,10 Paul Makhlouf,11 Monique Rothan-Tondeur1,12 1Chaire Recherche Sciences Infirmières, Laboratoire Educations et Promotion de la santé, LEPS, Université Sorbonne Paris Nord, Villetaneuse, France; 2Faculty of Public Health, Lebanese University, Fanar, Lebanon; 3Institut National de Santé Publique, d’Épidémiologie Clinique et de Toxicologie-Liban, INSPECT-LB, Beirut, Lebanon; 4Faculty of Public Health, Islamic University of Lebanon, Khaldeh - Beirut, Lebanon; 5School of Medicine, Lebanese Amerian University, Byblos, Lebanon; 6Department of Research, Faculty of Pharmacy, Lebanese University, Hadat, Lebanon; 7Department of Primary Care and Population Health, University of Nicosia Medical School, Nicosia, 2417, Cyprus; 8Department of Pulmonary Disease,Faculty of Medicine, Saint Joseph University, Beirut, Lebanon; 9Department of Pulmonary Disease, Maritime Hospital, Jbeil, Lebanon; 10Department of Pulmonary Disease, American University Medical Center Rizk Hospital, Beirut, Lebanon; 11Department of Pulmonary Disease, Notre Dame du Liban Hospital, Jounieh, Lebanon; 12Chaire Recherche Sciences Infirmières, AP-HP, Paris, FranceCorrespondence: Rita Georges Nohra, Université Sorbonne Paris Nord, Chaire Recherche Sciences Infirmières, Laboratoire Educations et Promotion de la santé, LEPS, 74 Rue Marcel Cachin, Villetaneuse, 93000, France, Tel +961 76 144 873 ; +33 7 67 23 36 34, Email Ritag.nohra@gmail.comPurpose: The objective of this study was to investigate the feasibility and pretest the effectiveness of an educational and telemonitoring program in a sample of Lebanese COPD patients to inform the design of a randomized study.Patients and Methods: This study recruited a convenient sample of 15 patients from the pulmonology departments of four hospitals. Validated questionnaires were adapted to meet the context of this study in terms of adequacy, acceptability, adoption, fidelity, and cost. The impact of this program on quality of life and anxiety was measured by the COPD Assessment Test (CAT), the COPD Clinical Questionnaire (CCQ), and the Hospital Anxiety and Depression Scale (HADS). All measurements were performed before and after the intervention.Results: All 15 participants who agreed to participate in this intervention found the program adequate and acceptable for addressing COPD-related issues. Regarding adoption, all participants declared having no difficulty explaining to others the content of the education sessions and that they would suggest this program to other COPD patients. In terms of effectiveness, six patients had improving in quality of life scores, and five patients had lower anxiety and depression scores compared to baseline measures. A knowledge assessment was done at the end of each session, showing an increase in knowledge for all participants. Skills were also assessed at the end of the program. Participants made no errors that had an impact on their health. Regarding the cost, it was difficult to evaluate the relative cost of this intervention given the economic situation in the country.Conclusion: This study is the first to evaluate the application of telehealth to optimize COPD management in Lebanon. The approach proposed gave insights into the different obstacles and facilitating factors for implementing such a project to allow a large-scale work on the adaptation of the COPD patient to his disease in Lebanon.Keywords: chronic obstructive pulmonary disease, quality of life, telehealth, knowledge, skills

Nelly Layoun,1,2 Pascal Salameh,2,3 Mirna Waked,4 Z Aoun Bacha,5 Rony M Zeenny,6 Eric El Hitti,4 Isabelle Godin,1 Michèle Dramaix1 1Research Center in Epidemiology, Biostatistics and Clinical Research, School of Public Health, UniversitéLibre de Bruxelles, Brussels, Belgium; 2Doctoral School of Sciences and Technologies, Lebanese University, Beirut, Lebanon; 3Clinical and Epidemiological Research Laboratory, Faculty of Pharmacy, Lebanese University, Beirut, Lebanon; 4Department of Pulmonology, St George Hospital University Medical Center; Faculty of Medicine, Balamand University, Beirut, Lebanon; 5Department of Pulmonary and Critical Care Medicine, Hotel-Dieu de France, Beirut, Lebanon; 6Pharmacy Practice Department, School of Pharmacy, Lebanese American University, Byblos, Lebanon Introduction: Health warnings on tobacco packages have been considered an essential pillar in filling the gap of knowledge and communicating the health risks of tobacco use to consumers. Our primary objective was to report the perception of smokers on the textual health warnings already appearing on tobacco packages in Lebanon versus shocking pictures about the health-related smoking consequences and to evaluate their impact on smoking behaviors and motivation. Methods: A pilot cross-sectional study was undertaken between 2013 and 2015 in five hospitals in Lebanon. Participants answered a questionnaire inquiring about sociodemographic characteristics, chronic respiratory symptoms, smoking behavior and motivation to quit smoking. Only-text warning versus shocking pictures was shown to the smokers during the interview. Results: Exactly 66% of the participants reported that they thought shocking pictorial warnings would hypothetically be more effective tools to reduce/quit tobacco consumption compared to only textual warnings. Also, 31.9% of the smokers who were motivated to stop smoking reported that they actually had stopped smoking for at least 1 month secondary to the textual warnings effects. A higher motivation to quit cigarette smoking was seen among the following groups of smokers: males (odds ratio [OR] =1.8, P=0.02), who had stopped smoking for at least 1 month during the last year due to textual warning (OR =2.79, P

Introduction We have already suggested that waterpipe (WP) smoking is associated with an increase in saliva cotinine and carbon monoxide in a small number of smokers. Objective The primary objective of this study was to confirm the increase in exhaled carbon monoxide (CO) and saliva cotinine equivalents levels in waterpipe smokers in a real smoking environment, compared with cigarettes smokers and never smokers. The secondary objective was to assess the factors associated with WP dependence according to the Lebanese Waterpipe Dependence Scale —11 (LWDS-11). Methods Three groups were included in the study: never smokers (n = 43), waterpipe smokers (n = 103), and cigarette smokers (n = 42). A questionnaire was completed for each participant, exhaled CO measured before and after waterpipe or cigarette smoking, and saliva cotinine equivalents dosed one hour after WP smoking or after one cigarette. Results Waterpipe smokers, like cigarette smokers, are exposed to nicotine and to CO. We found that levels of saliva cotinine equivalents were lower in waterpipe compared with cigarette smokers, but significantly higher than never smokers. In waterpipe smokers, saliva cotinine equivalents was mainly affected by the number of waterpipes per week and the size of the waterpipe. High levels were again found for expired CO, which increased by 500% in waterpipe smokers, in comparison with 100% in cigarette smokers; in waterpipe smokers, the relative increase in CO was affected by the number of waterpipes smoked before measurements, while it was inversely associated to the number of persons with whom they were sharing the WP and to the WP size. WP dependence was significantly correlated with the number of smokers at home, at work, and the body mass index. Conclusion This is a confirmation of real life waterpipe tobacco smoking characteristics in Lebanon. It indicates that nicotine is only marginally retained in the bowl water where smoke passes, and that waterpipe smokers could be exposed to harmful substances, such as CO that was found to be quite high. The level of expired CO and salivary cotinine could be good tools to detect exposure to waterpipe tobacco smoking. In addition, obesity and surrounding smokers could increase the risk of WP dependence.

Background: This study evaluated the benefits and impact of ICU therapeutic interventions on the survival and functional ability of severe cerebrovascular accident (CVA) patients.Methods: Sixty-two ICU patients suffering from severe ischemic/haemorrhagic stroke were evaluated for CVA severity using APACHE II and the Glasgow coma scale (GCS). Survival was determined using Kaplan-Meier survival tables and survival prediction factors were determined by Cox multivariate analysis. Functional ability was assessed using the stroke impact scale (SIS-16) and Karnofsky score. Risk factors, life support techniques and neurosurgical interventions were recorded. One year post-CVA dependency was investigated using multivariate analysis based on linear regression.Results: The study cohort constituted 6% of all CVA (37.8% haemorrhagic/62.2% ischemic) admissions. Patient mean(SD) age was 65.8(12.3) years with a 1:1 male: female ratio. During the study period 16 patients had died within the ICU and seven in the year following hospital release. The mean(SD) APACHE II score at hospital admission was 14.9(6.0) and ICU mean duration of stay was 11.2(15.4) days. Mechanical ventilation was required in 37.1% of cases. Risk ratios were; GCS at admission 0.8(0.14), (p = 0.024), APACHE II 1.11(0.11), (p = 0.05) and duration of mechanical ventilation 1.07(0.07), (p = 0.046). Linear coefficients were: type of CVA - haemorrhagic versus ischemic: -18.95(4.58) (p = 0.007), GCS at hospital admission: -6.83(1.08), (p = 0.001), and duration of hospital stay -0.38(0.14), (p = 0.40).Conclusion: To ensure a better prognosis CVA patients require ICU therapeutic interventions. However, as we have shown, where tests can determine the worst affected patients with a poor vital and functional outcome should treatment be withheld? [ABSTRACT FROM AUTHOR]

Background: The prevalence of eosinophilic asthma in Lebanon, one of the most severe phenotypes among severe asthma, is not known. This study aimed at determining the prevalence of the eosinophilic phenotype defined as an eosinophil count ≥ 300 cells/mm 3 among severe asthma patients in Lebanon., Methods: The Lebanese Chapter of the PREPARE study was a national, multicenter, cross-sectional observational study. Patients aged ≥ 12 years with severe asthma were identified and prospectively enrolled during clinic visits and completed the Global Initiative for Asthma (GINA) assessment of asthma control questionnaire. Patients' health characteristics were collected from medical records and blood samples were obtained for measurement of serum IgE levels and blood eosinophils count., Results: Overall, 101 patients (with mean age of 46.3 ± 17.0 years and 73.27% females) with severe asthma were included and, among them, 37% had eosinophilic phenotype, 67.3% had atopic phenotype with IgE > 100 IU/mL and 25.7% patients had overlapping atopic and eosinophilic phenotypes. Close to 80% had late-onset asthma, beyond 12 years of age, and around 85% had at least one severe exacerbation in the 12 months prior to study enrolment. The majority of participants [64.4%] had uncontrolled asthma, 24.7% had partially controlled symptoms and 10.9% had controlled symptoms. 19.8% of participants were on chronic oral corticosteroids, 78.2% had short course treatment of corticosteroids and all were prescribed a combination of inhaled corticosteroids and long-acting beta-agonist., Conclusions: The majority of patients with severe asthma were uncontrolled of which 37% present with an eosinophilic phenotype, which should be taken into consideration for better management of these patients in view of the novel phenotype-specific therapeutic options., (© 2023. Canadian Society of Allergy & Clinical Immunology.)

Proper management of stage III non-small cell lung cancer (NSCLC) might result in a cure or patient long-term survival. Management should therefore be preceded by adequate and accurate diagnosis and staging, which will inform therapeutic decisions. A panel of oncologists, surgeons and pulmonologists in Lebanon convened to establish a set of recommendations to guide and unify clinical practice, in alignment with international standards of care. Whilst chest computerized tomography (CT) scanning remains a cornerstone in the discovery of a lung lesion, a positron-emission tomography (PET)/CT scan and a tumor biopsy allows for staging of the cancer and defining the resectability of the tumor(s). A multidisciplinary discussion meeting is currently widely advised for evaluating patients on a case-by-case basis, and should include at least the treating oncologist, a thoracic surgeon, a radiation oncologist and a pulmonologist, in addition to physicians from other specialties as needed. The standard of care for unresectable stage III NSCLC is concurrent chemotherapy and radiation therapy, followed by consolidation therapy with durvalumab, which should be initiated within 42 days of the last radiation dose; for resectable tumors, neoadjuvant therapy followed by surgical resection is recommended. This joint statement is based on the expertise of the physician panel, available literature and evidence governing the treatment, management and follow-up of patients with stage III NSCLC., Competing Interests: The authors declare that they have no competing interests., (Copyright: © Aoun-Bacha et al.)

Pneumococcal disease affects people across all ages but is more prevalent in young children and the elderly. Despite the availability of the pneumococcal vaccine for adults, the disease burden and mortality associated with it remains a challenge. A few studies conducted in Lebanon have reported epidemiology of pneumococcal disease, concurring the high burden among adults and older adults in the region. The pneumococcal vaccine is a part of the routine immunization schedule for children, but there are no recommendations for adult vaccination. A medical advisory board was hence conducted in September 2020 to discuss the burden of pneumococcal disease (PD) among adults in Lebanon. The participants were experts from the fields of internal medicine, family medicine, hematology, cardiology, oncology, endocrinology, pulmonology, and infectious diseases. The experts reached a consensus that there is a need to take steps to increase the rate of adult vaccination uptake and create awareness among physicians, pharmacists, caregivers, and patients. The physicians should be trained on adult immunization and should actively discuss the importance of the pneumococcal vaccine, especially with high-risk adult patients. Implementing adult vaccination as a routine practice and involving various stakeholders to address the gaps can help in reducing the burden of pneumococcal disease in adults.

Background: We aimed at examining quitting behaviors among Lebanese cigarette smokers in order to clarify characteristics of adults who were more likely to intend to quit smoking., Study Design: A cross-sectional study., Methods: This study was conducted between March 2014 and March 2015, involving 382 patients randomly chosen from 5 outpatient clinics in 5 hospitals in Lebanon. A standardized questionnaire was completed including socio-demographic characteristics, smoking behavior, chronic respiratory symptoms, Fagerstrom scale, Mondor scale, packaging perception, quitting behavior and readiness to quit ladder., Results: 40.8% of participants reported having higher stages of readiness to quit while 33% and 7.9% of them intended to quit in 2 and 6 months later, respectively. Higher stages of readiness to quit were associated with high motivation to quit smoking (ORa=1.98; P=0.007), chronic wheezing and real quit attempt duration of ≥ 1 month (ORa=2.35, P=0.020 and ORa=2.15, P=0.003, respectively). Highly motivated smokers (ORa=1.83, P=0.040), who would have changed their favorite pack due to the graphical warnings (ORa=2.11, P=0.010) and who had past quit attempt (ORa=4.39, P<0.001) had more intention to quit in 2 months. Having past quit attempts would increase the intention to quit in 6 months by 7.48 times (ORa=7.48, P=0.007)., Conclusions: Significantly higher intentions to quit cigarette smoking were associated with a higher motivation and influenced by shocking images and health related warnings on tobacco boxes. We hope our results will initiate public health educational programs and interventions to surge the intention to quit cigarette smoking as the first step of quitting.

The relationship between smokers' knowledge about smoking related health problems and the motivation to quit smoking in a sample of Lebanese smokers was evaluated. The first group of smokers was composed of hospitalized subjects for a cardiologic or a respiratory health problem (n = 42). The second group was composed of smokers who have not suffered from any smoking-related health problem (n = 69). A positive correlation was found between the Richmond test score and the knowledge level about smoking related health problems (r = .302; p = .0013).

Background: The extent of smoking related health and economic problems is causing increasing alarm throughout the world. In the last few years a great number of subjects, especially in the developing world, have been smoking narghile and epidemiological studies on narghile smoking are an essential subject for investigation. The objectives of this study are to describe the social and cultural characteristics of narghile smokers in Lebanon compared to tobacco smokers., Materials and Methods: Our sample is based on the data of 37579 subjects who consulted a non-governmental organisation (NGO), the Hariri Foundation, between 2003 and 2005. This NGO comprises 22 specialised centres distributed throughout Lebanon. The following data concerning exclusive narghile and cigarette smokers were collected: age, sex, the type and duration of tobacco addiction and the level of education., Results: 13776 subjects (36.6% of the sample) were smokers of whom 88% smoked mostly cigarettes. 1529 subjects (11.1%) smoked narghile exclusively, a prevalence of 4.06%. The narghile smokers were younger than the cigarette smokers with a mean age of 36.2+/-8.63 years compared to 45.52+/-1.87 years. The majority of narghile smokers were women (56.57%) giving a male/female ratio of 0.77. A large number of narghile smokers were recent consumers with an exposure of less than 5 years. They differed from the cigarette smokers of whom the majority (72.2%) had smoked for more than 10 years. The proportion of illiterate subjects was greater among the narghile smokers (36.2%) than the cigarette smokers (24.2%)., Conclusion: The consumption of tobacco is a real and frequent problem in Lebanon. The consumption of narghile is scourge that is gaining popularity, notably among women and the young. This problem is becoming a public health issue that needs to be taken into account within the framework of an anti-smoking policy in Lebanon.

Cardiac surgery in patients with previous pneumonectomy is infrequently reported. We report a case of combined coronary artery bypass grafting and aortic valve replacement in a patient with left ventricular ejection fraction less then 35% and a previous right pneumonectomy. All steps in operative management of this rare condition are discussed.

Gastroesophageal reflux (GER) is a common situation that can express with digestive, extra-digestive, respiratory or otolaryngologic symptoms. Some chronic pulmonary disorders include in their setting GER as well. This review will address pathogenesis, clinical signs, complications and treatment of GER with a special focus towards the pulmonologist field. GER is a physiological post-prandial phenomenon of limited duration. It is induced by transient lower esophageal sphincter relaxation (tLESR) or by factors that impede LES function by reducing its tone or disrupting its contractions. Extra-digestive symptoms are caused by vagal stimulation through common autonomic pathways to the esophagus and bronchi. This reflex is triggered by gastric acid stimulation of esophageal receptors and by acid micro-aspirations into the airways. The responsibility of GER towards respiratory symptoms is often difficult to attest despite thorough investigations. Results of one to three-month treatment trial with proton pump inhibitors can be of value. Gastroesophageal assessment is mandatory as pulmonary manifestations might indicate disease severity.

All lung cancer cases admitted in our hospital from the 1st of January 1979 to the 31st of December 1995 were reviewed to allow for the study of the "behaviour" of the disease in Lebanon. A total of 386 cases included 87.5% males and 12.5% females. Mean age was 60 years. 87.3% were smokers. Squamous cell carcinoma was the most frequent histologic type (37.3%) and predominant in men. Adenocarcinoma was more frequent in women (50% v/s 29.9%). Patients often consulted their physician after delays of several months. Diagnosis is commonly confirmed by bronchoscopy. Transthoracic needle aspiration has become, since 1990, a very useful procedure for diagnosis of peripheral lesions with a sensitivity of 90.6%. Metastases are recorded in 30.9% of cases. Histological type distribution and advanced cancer stages found in our study are similar to that encountered in extensive international studies over the last few decades.