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Sickness absence remains a major challenge globally. Primary care physicians often find it challenging to deny patients' requests for sick leaves, making the gatekeeping role uneasy among doctors.Twenty-one PCPs participated in this non-randomized intervention study. The educational intervention consisted of an interactive presentation, a 20-minute video screening, and 3 text message reminders. The average number for sickness certificates (SCs), sickness absence rate per patient, and causes for sickness absence spells were measured one year before and one year after the intervention.The average number of SC one year before and after the intervention was 0.44 and 0.47, respectively. The sickness absence rate was 0.63% one year before and 0.75% one year after the intervention with no statistical significance. The mean number of sickness absence days did not significantly change. Causes for sickness absence spells significantly increased for diarrhea and back pain but decreased for upper respiratory infections with no statistical significance.Implementation of a multifaceted intervention to train PCPs on the process of sickness certification did not affect the sickness absence rate. Further research is needed to assess the knowledge and understanding of physicians' sickness certification process and the underlying factors that govern it to better develop tailored and effective interventions.

Capturing fluid composition variation and distribution in the reservoir is an essential first step for reservoir modeling. Vertical fluid composition variation is commonly considered. However, fluid samples taken from wells in different areas of a reservoir can highlight significant areal variation in the composition to be modeled. Fluid contacts may be tilted, and despite many studies on the subject, the setup is not straightforward. The combination of all three makes the initialization challenging and time consuming. In this paper we describe an automated workflow that integrates fluid sample data and petrophysical data to generate an initial fluid composition distribution that captures vertical and areal composition variations and accurately computes the initial fluid distribution to represent tilted contact configurations and their associated transition zones. Fluid sample data such as composition, pressure, temperature, and sampling depth are provided to an engine that computes composition variation with depth for each sample based on the equation of state (EOS) that characterizes the fluid behavior of the reservoir. The generated composition variation with depth for each sample is spatially distributed at their associated wells and is used to compute the areal composition distribution between the wells in the reservoir. This results in a tridimensional distribution of each fluid component representing the fluid model that captures both vertical and areal composition variations. In parallel, saturation height functions and hysteresis models are used to automatically generate drainage capillary pressure data and associated imbibition and scanning curves used to capture the drainage and imbibition processes responsible for the paleo and current water saturation distribution in the reservoir. The fully automated reservoir initialization process accounts for all available pressure-volume-temperature (PVT) samples. The solution is portable, significantly faster, and accurately captures complex reservoir geology and reservoir history. We present field examples of the proposed approach and illustrate its flexibility and associated comprehensiveness and efficiency. The complete automation of complex initialization methods considering areal and vertical composition variation, combined with tilted contacts modeling, is helping to resolve significant challenges faced across the industry.

Background Despite the growing burden of Alzheimer's disease and related dementias (ADRD) in low- to middle-income countries (LMICs) and prior findings of important gaps in research on ADRD knowledge, very few studies have assessed ADRD knowledge in these populations. This study evaluates the knowledge and attitudes towards ADRD among Lebanese middle-aged and older adults. Method Participants aged ≥ 40 (n = 215) attending primary care clinics at a large medical centre in Lebanon completed the Alzheimer's Disease Knowledge Scale (ADKS), an attitude scale, and the Duke University Religion Index. Results ADRD knowledge accuracy was 61.5% (mean score = 18.6 out of 30 (SD = 3.05)). Items with the least correct answers were related to caregiving and risk factors (≤9% and ≤28%). Overall, participants had tolerant views concerning ADRD; the least positive views were regarding living with people with ADRD. Older age, lower educational attainment, and higher religiosity scores were associated with poorer knowledge and attitudes. Conclusion Results highlight the need for awareness and preventive efforts that address misconceptions about modifiable risk factors and living with ADRD, especially given that the burden of caregiving for older adults often falls on family members in Lebanon and other LMIC countries.

Purpose: This paper evaluates the outcomes of parathyroidectomy for primary hyperparathyroidism with negative localization studies. Methods: All patients with primary hyperparathyroidism with negative preoperative ultrasound and MIBI scan who underwent parathyroidectomy were retrospectively included. Three groups were defined. Group 1 included the patients with negative ultrasound and MIBI. Group 2 included the patients with negative ultrasound and positive MIBI. Group 3 included the patients with positive ultrasound and negative MIBI. Results: In Group 1, 51% and 86% of patients had one adenoma and atypical localizations respectively. Unique adenoma and atypical localizations were showed in 87% and 93% of patients in Group 2 respectively. In Group 3, 83% and 17% of patients had one adenoma and atypical localizations respectively. No cervical hematoma was noted. Transient recurrent laryngeal nerve palsy occurred in 2 patients. Seven patients required postoperative calcium supplementation for 2 to 5 months, and one had recurrent hypercalcemia at follow-up. Cure rate was 98,3%. Conclusion: When US and MIBI were negative, multiple lesions and atypical localizations were frequent. The success rate and postoperative complications were not affected with this event.

Introduction This study aims to examine the sleep pattern and predictors of daily vs. as-needed use of hypnotics in middle-aged and older adults with insomnia. Methods Patients aged 50–75 who use hypnotics for insomnia were identified via electronic medical records and were recruited. Data about sociodemographics, mood and cognitive screening measures, and questions related to sleep patterns were collected through an interview conducted over the phone. Results A sample of 66 participants was recruited, of which 69.7% were females. Three quarters (49/66, 74.2%) used hypnotics daily, with 43% (21/49) of daily hypnotics users sleeping more than 8 h per night. Two-fifths (26/66, 39.4%) of participants still had clinically significant insomnia even after taking hypnotics. After adjusting for age, years of hypnotics use, sleeping hours per night, PHQ-2 score, and frequency of pain at night, the logistic regression model showed that younger age (p = 0.023) and longer sleeping hours per night (p = 0.025) were significantly associated with daily hypnotics use when compared to as needed hypnotics use. Conclusion Many hypnotic users still have clinically significant insomnia and poor quality of sleep as reflected by perceived longer sleep duration and more daytime napping which could be related to drug-related residual sedation. Hypnotic use may not be the best solution for insomnia treatment in an older population, and physicians should regularly reassess the use of hypnotics.

Despite the growing burden of Alzheimer's disease and related dementias (ADRD) in low- to middle-income countries (LMICs) and prior findings of important gaps in research on ADRD knowledge, very few studies have assessed ADRD knowledge in these populations. This study evaluates the knowledge and attitudes towards ADRD among Lebanese middle-aged and older adults.Participants aged ≥ 40 (n = 215) attending primary care clinics at a large medical centre in Lebanon completed the Alzheimer's Disease Knowledge Scale (ADKS), an attitude scale, and the Duke University Religion Index.ADRD knowledge accuracy was 61.5% (mean score = 18.6 out of 30 (SD = 3.05)). Items with the least correct answers were related to caregiving and risk factors (≤9% and ≤28%). Overall, participants had tolerant views concerning ADRD; the least positive views were regarding living with people with ADRD. Older age, lower educational attainment, and higher religiosity scores were associated with poorer knowledge and attitudes.Results highlight the need for awareness and preventive efforts that address misconceptions about modifiable risk factors and living with ADRD, especially given that the burden of caregiving for older adults often falls on family members in Lebanon and other LMIC countries.

Introduction Perioperative management of elderly patients differ from young patients due to physiologic and pharmacologic differences related to aging. Moreover, assessment for perioperative parameters and risks between age-matched elderly patients should be discerned while planning for the anaesthesia regimen. The latter could consist of opioid-free general anaesthesia (OFA) or non-opioid-free general anaesthesia (NOFA). Among the parameters for assessing the regimen's efficacy, time to extubate and pain control should be included. However, it is not yet established whether OFA could replace NOFA as a standard regimen for management of hip fracture. Therefore, the aim of this study is to evaluate the efficacy of OFA for hip surgeries in elderly patients. Methods This is a retrospective study consisting of patients undergoing hip surgeries under opioid-free or opioid-induced general anaesthesia. Two groups were defined: Group 1 consisting of treated patients using OFA and Group 2 consisting of treated patients using NOFA. Patient demographics (age, sex, and weight), mean time to extubate and mean dose of morphine after recovery were computed. Postoperative morphine use was assessed for up to 24 hours. Comparison of the computed data was conducted between both groups. Mean postoperative morphine use was compared using the Mann-Whitney U-test. The remainder of the means were compared using independent t-test. Qualitative data were compared using Fisher's exact test. Level of significance was set at p

Sleep disorders are highly prevalent in primary care. Obstructive sleep apnea (OSA) is one of the most common sleep disorders in the world, and it is estimated that only 10 to 20% of OSA cases are diagnosed. Primary care physicians (PCP) play an important role in screening for OSA. Knowledge of sleep disorders among PCP varies widely and has been generally reported as low. In this study, we aimed to assess the knowledge and attitudes towards OSA among primary care physicians in the Middle East and North Africa regions. A cross-sectional study using the Obstructive Sleep Apnea Knowledge and Attitudes (OSAKA) self-administered questionnaire was distributed to PCP attending the Lebanese Society of Family Medicine annual conference, the Lebanese Society of Internal Medicine annual conference, and World Organization of Family Doctors (WONCA) East Mediterranean region conference. Of 300 physicians approached, 256 (85%) completed the questionnaires. The range of possible scores was 0 to 18. The mean total knowledge score with standard deviation (SD) was 12.6 (2.5). Internal medicine specialists showed a higher mean knowledge score of 14.1 (2.3) compared to general/family medicine specialists 12.4 (2.4) and other specialties 11.9 (2.8), p = 0.001. Though 78% of all physicians felt confident in identifying patients with OSA, only 26% felt confident in managing patients with continuous positive airway pressure. Overall, there was a weak positive correlation between knowledge and attitude. There were gaps in knowledge and attitudes regarding managing patients with OSA. Training in managing patients with OSA is needed.

Dementia is projected to become a global health priority but often not diagnosed in its earlier preclinical stage which is mild cognitive impairment (MCI). MCI is generally referred as a transition state between normal cognition and Alzheimer’s disease. Primary care physicians play an important role in its early diagnosis and identification of patients most likely to progress to Alzheimer’s disease while offering evidenced-based interventions that may reverse or halt the progression to further cognitive impairment. The aim of this review is to introduce the concept of MCI in primary care through a case-based clinical review. We discuss the case of a patient with MCI and provide an evidence-based framework for assessment, early recognition and management of MCI while addressing associated risk factors, neuropsychiatric symptoms and prognosis.

Much less is known about the effect of advanced paternal age (APA) (≥40 years) than advanced maternal age on neonatal morbidity. More specifically, the correlation with low birth weight remains inconsistent. This study aims to determine whether APA among mothers aged 20-29 years is associated with a higher risk of low birth weight and other neonatal outcomes.Data from 2004 to 2008 database of the National Collaborative Perinatal Neonatal Network were used. Fifteen thousand two hundred eighteen live birth singleton pregnancies by primigravida mothers aged 20-29 years were analyzed. Study variables include paternal age (years), C-section delivery (yes/no), low birth weight (2500 g), and preterm births (37 weeks of gestation). Regressions were generated controlling for birth defects, consanguinity, maternal education, prenatal care, gender, and maternal smoking.Adjusted odds of Low Birth Weight (LBW) and Cesarean Section Deliveries (CSD) were significantly higher in infants of APA fathers compared to those of fathers aged 30-35 years [adjusted odds ratio (95% confidence interval) = 1.5 (1.1, 2.3) and 1.4 (1.1, 1.7), respectively]. Paternal ages of 35-39 years compared to less than 30 years were associated with higher odds of CSD [adjusted odds ratio = 1.4 (1.2, 1.5)]. APA was not associated with preterm birth after adjustment.This study supports the association between APA and increased risk for LBW and CSD.

Objective Mild Cognitive Impairment (MCI) is an intermediate state between normal cognition and dementia. Identification of MCI and associated risk factors is important for early intervention. This study investigated the prevalence of MCI among Lebanese older adults and associated risk factors in primary care. Methods For this cross-sectional study, 337 adults aged 60 years and older met inclusion criteria and were recruited at a primary care clinic associated with a tertiary medical center in Beirut, Lebanon. The validated Arabic version of the Montreal Cognitive Assessment, the 5-item Geriatric Depression Scale, and the Lawton Instrumental Activities of Daily Living Scale were administered. Data about sociodemographic, behavioral, and clinical characteristics was obtained. Results There was no difference in the mean age between those with normal cognition and those with MCI (mean age 70.38 ± 7.4 and 72.12 ± 7.6 years, respectively). The prevalence of MCI was 14.8% (50 out of 337), 42% were males and 58% were women. Participants having more than 12 years of education (OR = 0.297; CI = 0.112–0.788; P = 0.015) were less likely to have MCI. Participants with history of smoking (OR = 2.599; CI = 1.266–5.339; P = 0.012) or at risk of depression (OR = 2.847; CI = 1.392–5.819; P = 0.004) were more likely to have MCI. Conclusion Identification of patients with history of smoking and at risk of depression may serve as an opportunity to offer intensive counseling and targeted treatment to delay the onset or progression of MCI to Alzheimer’s disease.

ObjectiveTo assess awareness and attitudes towards engaging in advance care planning (ACP) and their relationship with demographic, socioeconomic and religiosity factors among Lebanese middle-aged to older-aged adults in primary care.DesignA cross-sectional survey study.SettingTertiary referral hospital in Beirut, Lebanon.ParticipantsA total of 215 middle-aged to older-aged adults.ResultsOut of 215 participants, 18.6% of participants knew about ACP; 94% favoured truth-telling; 87.4% favoured healthcare autonomy; 77.2% favoured documenting their own health values and preferences; and 29.3% were willing to undergo life-prolonging interventions. Among participants who were aware of ACP, 67.5% preferred ACP documentation and 85% had negative attitudes towards life-sustaining interventions. Women were more aware about ACP than men. Those who were willing to undergo life-prolonging interventions were found to be men and had higher religiosity scores.ConclusionLarge deficit in ACP awareness was evident despite the high preference for healthcare autonomy. Medical and public health efforts should strive to enhance patients’ ACP awareness and engagement in ACP while considering factors relevant to gender, culture and religiosity.

Purpose Prostate cancer care in the Middle East is highly variable and access to specialist multidisciplinary management is limited. Academic tertiary referral centers offer cutting-edge diagnosis and treatment; however, in many parts of the region, patients are managed by non-specialists with limited resources. Due to many factors including lack of awareness and lack of prostate-specific antigen (PSA) screening, a high percentage of men present with locally advanced and metastatic prostate cancer at diagnosis. The aim of these recommendations is to assist clinicians in managing patients with different levels of access to diagnostic and treatment modalities. Methods The first Advanced Prostate Cancer Consensus Conference (APCCC) satellite meeting for the Middle East was held in Beirut, Lebanon, November 2017. During this meeting a consortium of urologists, medical oncologists, radiation oncologist and imaging specialists practicing in Lebanon, Syria, Iraq, Kuwait and Saudi Arabia voted on a selection of consensus questions. An additional workshop to formulate resource-stratified consensus recommendations was held in March 2019. Results Variations in practice based on available resources have been proposed to form resource-stratified recommendations for imaging at diagnosis, initial management of localized prostate cancer requiring therapy, treatment of castration-sensitive/naïve advanced prostate cancer and treatment of castration-resistant prostate cancer. Conclusion This is the first regional consensus on prostate cancer management from the Middle East. The following recommendations will be useful to urologists and oncologists practicing in all areas with limited access to specialist multi-disciplinary teams, diagnostic modalities and treatment resources. Electronic supplementary material The online version of this article (10.1007/s00345-019-02872-x) contains supplementary material, which is available to authorized users.

This paper examines the joint impact that governance structure and economic regulation has on airport efficiency. The previous literature has focused on one or the other of these factors but not both. The empirical investigation uses a semi-parametric Bayesian distance stochastic frontier model, as well as a Data Envelopment Analysis (DEA) model. Based on a panel of airports in several countries we find that the form of economic regulation is relatively more important than the type of governance in affecting efficiency. The article provides measures of changes in expected efficiency when either or both the governance form and price regulation changes.

The Pfizer Green Chemistry metrics program is described and exemplified with a case history involving the synthesis of (S,S)-reboxetine succinate. The initial route used a classical resolution approach and generated high levels of waste. This route was replaced by an enantiospecific synthesis which used Sharpless epoxidation chemistry, an enzymatic process to selectively protect a primary alcohol and a new efficient method of chiral morpholine construction as key steps. These improvements reduced the levels of waste produced by the synthesis by more than 90%. Detailed metrics starting from a common starting material (trans-cinnamyl alcohol) for all routes of synthesis are presented.

The development of a synthetic process for (S,S)-reboxetine succinate, a candidate for the treatment of fibromylagia, is disclosed from initial scale-up to deliver material for registrational stability testing through to commercial route evaluation and subsequent nomination. This entailed evaluation of several alternative routes to result in what would have been a commercially attractive process for launch of the compound.

This study uses the data envelopment analysis (DEA) double bootstrap approach to assess the technical efficiency standing of Australian hotels. Two inputs and six outputs were used in the analyses for the period 2004–2007. The empirical results indicate that the DEA bootstrap approach corrects for the bias inherent in traditional DEA models. The results show that the average technical efficiency of Australian hotels has improved gradually from 76.17% in 2004 to reach its highest level of 80.84% in 2007. The results also indicate that the key determinants of the technical efficiency of Australian hotels are the number of years in business, location, star rating and physical size. The implications of the results are discussed.

We report our results on the construction of a morpholine ring system from the corresponding epoxide and amino alcohol. From this study, we were able to convert a previous four-step synthesis into a more efficient two-step process.

We report the case of a five-year-old child who had a hard painless left testis discovered on a routine physical examination. He underwent a left inguinal orchiectomy, and the pathology examination revealed a dermoid cyst of the testis. This is a rare tumor, considering the low incidence of testicular tumors in childhood. Histologic criteria and surgical management are also presented. We believe this report is the first well-documented case.