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OBJECTIVE: To assess the completeness of data on death certificates over the past 25 years in Beirut, Lebanon, and to examine factors associated with the absence of certifiers' signatures and the non-reporting of the underlying cause of death. METHODS: A systematic 20% sample comprising 2607 death certificates covering the 1974, 1984, 1994, 1997 and 1998 registration periods was retrospectively reviewed for certification practices and missing data. FINDINGS: The information on the death certificates was almost complete in respect of all demographic characteristics of the deceased persons except for occupation and month of birth. Data relating to these variables were missing on approximately 95% and 78% of the certificates, respectively. Around half of the certificates did not carry a certifier's signature. Of those bearing such a signature, 21.6% lacked documentation of the underlying cause of death. The certifier's signature was more likely to be absent on: certificates corresponding to the younger and older age groups than on those of persons aged 15-44 years; those of females than on those of males; those of persons who had been living remotely from the registration governorate than on those of other deceased persons; and those for which there had been delays in registration exceeding six months than on certificates for which registration had been quicker. For certificates that carried the certifier's signature there was no evidence that any of the demographic characteristics of the deceased person was associated with decreased likelihood of reporting an underlying cause of death. CONCLUSION: The responsibility for failure to report causes of death in Beirut lies with families who lack an incentive to call for a physician and with certifying physicians who do not carry out this duty. The deficiencies in death certification are rectifiable. However, any changes should be sensitive to the constraints of the organizational and legal infrastructure governing death registration practices and the medical educational systems in the country.

Abstract Background We aimed at assessing the degree of measurement error in essential fatty acid intakes from a food frequency questionnaire and the impact of correcting for such an error on precision and bias of odds ratios in logistic models. To assess these impacts, and for illustrative purposes, alternative approaches and methods were used with the binary outcome of cognitive decline in verbal fluency. Methods Using the Atherosclerosis Risk in Communities (ARIC) study, we conducted a sensitivity analysis. The error-prone exposure – visit 1 fatty acid intake (1987–89) – was available for 7,814 subjects 50 years or older at baseline with complete data on cognitive decline between visits 2 (1990–92) and 4 (1996–98). Our binary outcome of interest was clinically significant decline in verbal fluency. Point estimates and 95% confidence intervals were compared between naïve and measurement-error adjusted odds ratios of decline with every SD increase in fatty acid intake as % of energy. Two approaches were explored for adjustment: (A) External validation against biomarkers (plasma fatty acids in cholesteryl esters and phospholipids) and (B) Internal repeat measurements at visits 2 and 3. The main difference between the two is that Approach B makes a stronger assumption regarding lack of error correlations in the structural model. Additionally, we compared results from regression calibration (RCAL) to those from simulation extrapolation (SIMEX). Finally, using structural equations modeling, we estimated attenuation factors associated with each dietary exposure to assess degree of measurement error in a bivariate scenario for regression calibration of logistic regression model. Results and conclusion Attenuation factors for Approach A were smaller than B, suggesting a larger amount of measurement error in the dietary exposure. Replicate measures (Approach B) unlike concentration biomarkers (Approach A) may lead to imprecise odds ratios due to larger standard errors. Using SIMEX rather than RCAL models tends to preserve precision of odds ratios. We found in many cases that bias in naïve odds ratios was towards the null. RCAL tended to correct for a larger amount of effect bias than SIMEX, particularly for Approach A.

Background: There are limited studies examining the role of BMI on mortality in the trauma population. The aim of this study was to analyze whether the "obesity paradox" exists in non-elderly patients with blunt trauma., Methods: A retrospective study was performed on the Trauma Quality Improvement Program (TQIP) database for 2016. All non-elderly patients aged 18-64, with blunt traumatic injuries were identified. A generalized additive model (GAM) was built to assess the association of mortality and BMI adjusted for age, gender, race, and injury severity score (ISS)., Results: 28,475 patients (mean age = 42.5, SD = 14.3) were identified. 20,328 (71.4%) were male. Age (p < 0.0001), gender (p < 0.0001), and ISS (p < 0.0001) had significant associations with mortality. After GAM, BMI showed a significant U-shaped association with mortality (EDF = 3.2, p = 0.003). A BMI range of 31.5 ± 0.9 kg/m 2 was associated with the lowest mortality., Conclusion: High BMI can be a protective factor in mortality within non-elderly patients with blunt trauma. However, underweight or morbid obesity suggest a higher risk of mortality., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To assess characteristics of patients with hip fractures and investigate the extent of osteoporosis-related care they receive at a tertiary referral center in Lebanon., Methods: A retrospective review of charts of 400 patients admitted with a hip fracture to the American University of Beirut-Medical Center, between January 1, 2011 and December 31, 2015. We reviewed medical records of adults admitted with a nonpathologic/nontraumatic hip fracture, and evaluated basic demographics and relevant clinical information, associated risk factors, and the management received., Results: The mean age of the population was 78 ± 10 years and men constituted 37%. Women were more likely to be assessed and/or treated. On admission, 21% were taking calcium and 18% vitamin D supplementation. During hospitalization, vitamin D level was assessed in only 39% of patients; a dietary and an osteoporosis consult were requested on only 32% and 22% of the cases, respectively. One-fourth to a third of patients were discharged on calcium or vitamin D, and less than 5% on bisphosphonates. Bone mineral density was measured in a minority although 21% had a history of previous contralateral hip fracture. One year mortality rate in a subset where follow-up available was 12% in men and 7% in women., Conclusion: A large care gap in the management of patients admitted with hip fracture persists despite clear national osteoporosis guidelines. This study provides a strong impetus for establishing and monitoring a fracture liaison service to understand and address barriers to providing optimal care to patients with osteoporosis., (Copyright © 2019 The International Society for Clinical Densitometry. Published by Elsevier Inc. All rights reserved.)

The Iron and Classical Ages in the Near East were marked by population expansions carrying cultural transformations that shaped human history, but the genetic impact of these events on the people who lived through them is little-known. Here, we sequenced the whole genomes of 19 individuals who each lived during one of four time periods between 800 BCE and 200 CE in Beirut on the Eastern Mediterranean coast at the center of the ancient world's great civilizations. We combined these data with published data to traverse eight archaeological periods and observed any genetic changes as they arose. During the Iron Age (∼1000 BCE), people with Anatolian and South-East European ancestry admixed with people in the Near East. The region was then conquered by the Persians (539 BCE), who facilitated movement exemplified in Beirut by an ancient family with Egyptian-Lebanese admixed members. But the genetic impact at a population level does not appear until the time of Alexander the Great (beginning 330 BCE), when a fusion of Asian and Near Easterner ancestry can be seen, paralleling the cultural fusion that appears in the archaeological records from this period. The Romans then conquered the region (31 BCE) but had little genetic impact over their 600 years of rule. Finally, during the Ottoman rule (beginning 1516 CE), Caucasus-related ancestry penetrated the Near East. Thus, in the past 4,000 years, three limited admixture events detectably impacted the population, complementing the historical records of this culturally complex region dominated by the elite with genetic insights from the general population., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Ischemic stroke among hospitalized patients who underwent surgical or endovascular therapies for unruptured intracranial aneurysms (IAs) has not been previously examined in nationally representative samples., Objectives: The purpose of this study is to compare the occurrence and in-hospital outcomes (nonroutine discharge, length of stay) of perioperative ischemic stroke among hospitalized patients diagnosed with unruptured IA across treatment selection [surgical clipping, endovascular coiling, stent- or balloon-assisted coiling (SAC or BAC), combined clipping and coiling]., Methods: A cross-sectional study was conducted using 23,053 hospital discharge records from the 2002-2012 Nationwide Inpatient Sample (NIS). Rates, β coefficients, and odds ratios (ORs) with their 95% confidence intervals (CIs) were calculated accounting for survey design complexity, patient- and hospital-level confounders., Results: Ischemic stroke rate was 6.9% [surgical clipping (4.3%), endovascular coiling (8.1%), BAC or SAC (1.9%), and combined techniques (4.2%)]. Multivariable logistic regression models suggested that compared to patients undergoing surgical clipping alone, those undergoing SAC or BAC were less likely to be diagnosed with ischemic stroke (adjusted OR=0.34, 95% CI: 0.14, 0.85). Compared to clipping, endovascular techniques resulted in fewer nonroutine dispositions and shorter hospitalizations, whereas combined techniques resulted in longer hospitalizations. Differences in hospitalization outcomes between treatment types were only affected by ischemic stroke when comparing coiling to clipping., Conclusions: Perioperative ischemic stroke rate among patients with unruptured IA may be less among those undergoing SAC or BAC as compared to those undergoing surgical clipping alone. Improved in-hospital outcomes among coiling versus clipping recipients may depend on ischemic stroke diagnosis., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Beydoun et al.)

Objectives: Adherence with diet and prescribed purgative is essential for proper cleansing with low-volume bowel preparations. The aim of this work was to assess the effect of a customized mobile application (App) on adherence and quality of bowel preparation., Methods: One hundred and sixty (160) eligible patients scheduled for elective colonoscopy were randomly assigned to paper (control) or App-based instructions. The preparation consisted of low-fiber diet for 2 days, clear fluids for one day and split-dose sodium picosulfate/magnesium citrate (SPS). Before colonoscopy, information was collected regarding adherence with, and utility of the provided instructions. The colonoscopists, blinded to assignment, graded bowel preparation using the Aronchick, Ottawa, and Chicago preparation scales. The primary endpoint was adherence with instructions. Quality of preparation was a secondary endpoint., Results: No difference in overall adherence or bowel cleanliness was observed between the study arms. Adherence was reported in 82.4% of App vs. 73.4% of controls (P=0.40). An adequate bowel preparation on the Aronchick scale was noted in 77.2 vs. 82.5%, respectively (P=0.68). Mean scores on the Ottawa and Chicago scales were also similar. Gender, age, time of colonoscopy, and BMI did not influence preparation or adherence. Compliance with the clear fluid diet component was noted in 94% of patients with BMI<30 vs. 77% with BMI≥30 (P<0.01). SPS was well tolerated by 81.9% of patients. The App was user-friendly and received higher overall rating in this respect than paper instructions (P<0.01)., Conclusions: SPS is well tolerated and effective for bowel cleansing regardless of instruction method. Customized smartphone applications are effective, well-accepted and could replace standard paper instructions for bowel preparation.ClinicalTrials.gov: NCT02410720., Competing Interests: Guarantor of the article: Ala I. Sharara, MD, FACG, AGAF. Specific author contributions: Ala I. Sharara: Study idea, concept, design and supervision, App design and development, patient recruitment, data collection and interpretation of the data, review of the literature; drafting of the manuscript. Jean M. Chalhoub: data collection, statistical analysis, interpretation of the data, review of literature, regulatory administration, critical review of the manuscript. Maya Beydoun: literature review, App development and design, data collection, regulatory administration, drafting of the manuscript. Rani H. Shayto: data analysis, regulatory administration, drafting of the manuscript. Ali H. Harb: review of literature, App design and development, regulatory administration, patient recruitment, critical review of the manuscript. Hamed Chehab: patient recruitment, data collection, regulatory administration, critical review of the manuscript. Fadi Mourad: patient recruitment, data interpretation, critical review of the manuscript. Fayez S. Sarkis: study design, critical review of the manuscript. All authors approved the submitted version of the manuscript. Financial support: This work was supported by a restricted research grant for an investigator-initiated study from Ferring Pharmaceuticals (AIS). Potential competing interests: None.

The purpose of this cross-sectional study based on the 2001-2006 National Health and Nutrition Examination Survey is to examine demographic, socioeconomic, lifestyle and reproductive characteristics that may distinguish users and non-users of insulin sensitizing agents among the US diabetic, borderline diabetic and non-diabetic women. Use of insulin-sensitizing agents was evaluated among 19,579 (3882 diabetic, 387 borderline diabetic and 15,310 non-diabetic) women. Overall, 2% of women in the study sample were users of insulin-sensitizers, including metformin, rosiglitazone and pioglitazone. Multivariate logistic regression models were constructed for predictors of insulin-sensitizer use according to diabetic status. In the overall sample, being younger or diabetic were the only factors associated with an increased odds of using insulin-sensitizing agents, after adjustment of confounders. Among diabetics, use of insulin-sensitizing agents was inversely related to age, but not other factors in the multivariable model. Among borderline and non-diabetics, body mass index (BMI) was the only predictor that remained significantly associated with the use of insulin-sensitizing agents after controlling for confounders. In conclusion, the main predictors of insulin-sensitizer use are young age and diabetic status in all women, young age in diabetic women and high BMI in borderline and non-diabetic women.

Although endoscopic ultrasound-guided fine needle aspiration (EUS-guided FNA) of the left adrenal gland is safe and accurate compared to the percutaneous approach, there are no reports to our knowledge about EUS-guided FNA of the right adrenal gland performed in Lebanon and the Middle East. We report the case of a 64-year-old male who presented with a swollen right calf and right flank pain and was diagnosed with deep vein thrombosis with a right calf deep venous thrombosis. A computerized tomography of the chest and abdomen revealed a round solid mass of the right adrenal gland, a right upper lobe mass and centrilobular emphysema of both lungs. Percutaneous biopsy of the right adrenal gland was declined as the patient was quoted a high risk of bleeding. EUS-guided FNA of the right adrenal was performed via the transduodenal approach confirming the final diagnosis of metastatic lung cancer. This case shows that the right adrenal gland can be sampled with EUS-FNA via the duodenal approach to diagnose metastatic lung cancer, especially when the percutaneous approach is not feasible.

This study tested the general economic theory of fertility within the contextual setting of the Lebanese society, by using the 1996 Population and Housing Database Survey. The theory argues that the household's demand for a child is closely related to different services and utilities ascribed to that child. It also claims that fertility as such is income-inelastic, but becomes positively associated with the household's income when the notion of child-quality is added to the model. Findings confirm the baseline inverse association between an index of the household's socioeconomic status (HSES) and the cumulative fertility level. However, when women's education was added to the model, an interaction was observed whereby the illiterate subgroup--unlike the educated--was at higher risk of having a large number of children with improvement in their economic conditions. A similar interaction was found between women's and husband's education. It was concluded that in response to higher socioeconomic status, illiterate women end up supplying an excess number of children, an effect mediated by the shortening of lactation period, which is in turn triggered by a higher access to breast milk substitutes. On the other hand, their educated husbands demand 'child quantity' since this educational gap grants them more power to decide their family size. In contrast, educated women demand child 'quality' as they expect both material and opportunity costs of having a child to coincide with the norms and values of their social class. Their lower supply of births with increased economic well-being is primarily attributed to a higher use of modern contraceptive methods. Other factors investigated in this study included the potential effect of family structure on fertility, and control was done on a number of other sociocultural and demographic variables, such as women's work status, husband's occupation, age at marriage and area of residence.

Radiologic experience in 67 patients with melanoma metastatic to all portions of the gastrointestinal tract is reviewed. Besides the well known "bull's-eye" lesion of the upper gastrointestinal tract, a large variety of radiologic presentations of melanoma metastases is discussed and illustrated. Because of extended survival due to improved chemotherapy and immunotherapy, the importance of careful radiologic examination of the melanoma patient is stressed.