Burnout among postgraduate medical trainees in Lebanon: Potential strategies to promote wellbeing

ObjectiveBurnout is a widespread issue in healthcare for many years. Lebanon combatted political and economic crises before the coronavirus disease 2019 (COVID-19) pandemic, in addition to the port explosion in August 2020. The study aimed to identify the determinants of personal burnout, patient-related burnout, and work-related burnout among postgraduate medical trainees (PGMT) and evaluate its relationship with sociodemographic characteristics.DesignA cross-sectional study utilized the Copenhagen Burnout Inventory (CBI) involving electronic, voluntary, and anonymous survey. The survey was completed by 188 PGMT including residents and fellows from all specialties and all levels of training.ResultsThe prevalence rates are 68.6% for personal burnout, 63.3% for work-related burnout, and 35.1% for patient-related burnout.ConclusionResults improve our understanding of the phenomenon of burnout, and the role of program leadership in shaping the impact of burnout on training and promoting wellbeing of PGMT. Discussion focuses on providing potential wellbeing strategies for program directors to follow for mitigating burnout

Inflammatory and Repair Serum Biomarker Pattern. Association to Clinical Outcomes in COPD

Background: The relationship between serum biomarkers and clinical expressions of COPD is limited. We planned to further describe this association using markers of inflammation and injury and repair. Methods: We studied lung function, comorbidities, exercise tolerance, BODE index, and quality of life in 253 COPD patients and recorded mortality over three years. Serum levels of Interleukins 6,8 and16, tumor necrosis factor alpha (TNF α) [inflammatory panel], vascular endothelial growth factor (VEGF), and matrix metalloproteinase 9 (MMP-9) [injury and repair panel] and pulmonary and activation-regulated chemokine (PARC/CCL-18) and monocyte chemotactic protein 1 (MCP-1/CCL2) [chemoattractant panel] were measured. We related the pattern of the biomarker levels to minimal clinically important differences (MCID) using a novel visualization method [ObServed Clinical Association Results (OSCAR) plot]. Results: Levels of the inflammatory markers IL-6, TNF α were higher and those of injury and repair lower (p < 0.01) with more advanced disease (GOLD 1 vs. 4). Using the OSCAR plot, we found that patients in the highest quartile of inflammatory and lowest quartile of injury and repair biomarkers level were more clinically compromised and had higher mortality (p < 0.05). Conclusions: In COPD, serum biomarkers of inflammation and repair are distinctly associated with important clinical parameters and survival

The International Medical Graduate

International medical graduates (IMGs) are graduates of medical schools located outside the United States (U.S.) and Canada. IMGs face various challenges on the road to U.S. residency training. These challenges include sitting for the United States Medical Licensing Examinations (USMLEs) to obtain certification from the Educational Commission for Foreign Medical Graduates (ECFMG). After that, IMGs are faced with a foreign application process whereby they must apply for and secure a position in a residency program through the Electronic Residency Application System (ERAS) and the National Resident Matching Program (NRMP). Once accepted into a residency program, IMGs who are not US citizens or legal permanent residents are challenged with securing a visa to be able to practice in the U.S. In this article, we elaborate on these processes and highlight the challenges IMGs may face along the way

Nondepolarizing muscle relaxant improves direct laryngoscopy view with no effect on face mask ventilation

Background: Difficult or impossible face mask ventilation complicated with difficult tracheal intubation during anesthesia induction occurs in 0.4% of adult anesthesia cases, possibly leading to life-threatening complications. Because of such catastrophes, muscle relaxants have been recommended to be administered after confirming adequate face mask ventilation without a solid scientific validation of this principal. Methods: In this observational study, the ease of ventilation and the scores of direct laryngoscopy views before and after administration of cisatracurium were assessed in ninety young healthy adults, without anesthetic risks and without foreseen difficult intubation and who were scheduled for general elective surgeries. Results: Before muscle relaxation, 43 patients (48%) were Cormack Grade I, while the remaining 47 patients (52%) were either Cormack Grade II (28 patients, 31%) or Cormack Grade II (19 patients, 21%). Following muscle relaxation with cisatracurium, the number of patients with Cormack Grade I significantly increased from 43 patients (48%) to 65 patients (72%) (p = 0.0013). Only 1 patient out of 19 patients (5%) improved his Cormack grade from Grade III to Grade I while 16 out 19 patients (84%) improved their Cormack grade from Grade III to Grade II after the use of cisatracurium. The quality of face mask ventilation did not differ with and without muscle relaxants in all patients. Conclusion: The use of cisatracurium in healthy young adults undergoing general elective surgeries with no anticipated difficult endotracheal intubation had no effect on the quality of face mask ventilation despite resulting in a quantifiable improvement in the laryngeal view. Resumo: Justificativa: A ventilação difícil ou impossível via máscara facial complicada pela intubação traqueal difícil durante a indução da anestesia ocorre em 0,4% dos casos de anestesia em adultos, possivelmente levando a complicações fatais. Devido a tais catástrofes, recomendou-se que a administração de relaxantes musculares seja feita após a confirmação de ventilação adequada via máscara facial, sem uma validação científica sólida dessa conduta. Métodos: Neste estudo observacional, a facilidade de ventilação e os escores de visibilidade em laringoscopia direta antes e após a administração de cisatracúrio foram avaliados em 90 adultos jovens e saudáveis, sem riscos anestésicos e sem intubação difícil prevista, agendados para cirurgias eletivas gerais. Resultados: Antes do relaxamento muscular, 43 pacientes (48%) eram Cormack Grau I, enquanto os 47 pacientes (52%) restantes eram ou Cormack Grau II (28 pacientes, 31%) ou Cormack Grade III (19 pacientes, 21%). Após o relaxamento muscular com cisatracúrio, o número de pacientes com Cormack Grau I aumentou significativamente de 43 (48%) para 65 pacientes (72%) (p = 0,0013). Apenas um paciente (5%) dos 19 melhorou sua classificação de Cormack do Grau III para o Grau I, enquanto 16 dos 19 pacientes (84%) melhoraram suas classificações de Cormack do Grau III para o grau II após o uso de cisatracúrio. A qualidade da ventilação via máscara facial não diferiu com ou sem relaxantes musculares em todos os pacientes. Conclusão: O uso de cisatracúrio em adultos jovens saudáveis submetidos a cirurgias eletivas gerais sem intubação traqueal difícil prevista não teve efeito sobre a qualidade da ventilação via máscara facial, mesmo resultando em melhora quantificável da visibilidade da laringe. Keywords: Nondepolarizing muscle relaxants, Laryngoscopy view, Face mask ventilation, Palavras-chave: Relaxantes musculares não despolarizantes, Visibilidade em laringoscopia, Ventilação via máscara facia

Multisource Groundwater Contamination under Data Scarcity: The Case Study of Six Municipalities in the Proximity of the Naameh Landfill, Lebanon

Lebanon is affected by a protracted environmental and solid waste crisis that is threatening the water resources and the public health of its communities. This study is part of a public participatory research project that aims to evaluate the impacts of solid waste disposal practices on water, air, and health in six villages of Lebanon, stigmatized by the presence of a regional landfill. Community mapping enabled the selection and testing of seven springs and three wells in the upstream basin and 11 wells in the lower basin, covering a broad list of chemical, physical, and bacteriological parameters. Two water quality indices (WQ-1 and WQ-2) were used to assess water quality in the study area. The results for the upstream wells and springs showed a significant bacteriological contamination, while the results in the lower wells showed high levels of conductivity, chlorides, and zinc along with the occurrence of organic micropollutants in trace concentrations. The comparison between the experimental data, with the natural background value established in the same area, did not show major differences, except for zinc and bacteriological indicators. The bacteriological contamination is most likely related to sewage infiltration into groundwater at the time of the assessment. Zinc may result from landfill leachate infiltration but also well corrosion. Saltwater intrusion affecting the coastal basin is masking the results for conductivity, chlorides, and sulfates, whereas the presence of small traces of organic micropollutants in the coastal aquifer may be related to leachate infiltration. WQI-1 results, which included bacteriological indicators, showed highly degraded water quality in the C1-C3 inner basin. In contrast, WQI-2, which includes physio-chemical indicators only, showed good water quality, slightly deteriorating in the coastal area, downstream of the Naameh landfill

Inflammatory and repair serum biomarker pattern. Association to clinical outcomes in COPD

Abstract Background The relationship between serum biomarkers and clinical expressions of COPD is limited. We planned to further describe this association using markers of inflammation and injury and repair. Methods We studied lung function, comorbidities, exercise tolerance, BODE index, and quality of life in 253 COPD patients and recorded mortality over three years. Serum levels of Interleukins 6,8 and16, tumor necrosis factor alpha (TNF α) [inflammatory panel], vascular endothelial growth factor (VEGF), and matrix metalloproteinase 9 (MMP-9) [injury and repair panel] and pulmonary and activation-regulated chemokine (PARC/CCL-18) and monocyte chemotactic protein 1 (MCP-1/CCL2) [chemoattractant panel] were measured. We related the pattern of the biomarker levels to minimal clinically important differences (MCID) using a novel visualization method [ObServed Clinical Association Results (OSCAR) plot]. Results Levels of the inflammatory markers IL-6, TNF α were higher and those of injury and repair lower (p  Conclusions In COPD, serum biomarkers of inflammation and repair are distinctly associated with important clinical parameters and survival.</p

Nondepolarizing muscle relaxant improves direct laryngoscopy view with no effect on face mask ventilation

Abstract Background: Difficult or impossible face mask ventilation complicated with difficult tracheal intubation during anesthesia induction occurs in 0.4% of adult anesthesia cases, possibly leading to life-threatening complications. Because of such catastrophes, muscle relaxants have been recommended to be administered after confirming adequate face mask ventilation without a solid scientific validation of this principal. Methods: In this observational study, the ease of ventilation and the scores of direct laryngoscopy views before and after administration of cisatracurium were assessed in ninety young healthy adults, without anesthetic risks and without foreseen difficult intubation and who were scheduled for general elective surgeries. Results: Before muscle relaxation, 43 patients (48%) were Cormack Grade I, while the remaining 47 patients (52%) were either Cormack Grade II (28 patients, 31%) or Cormack Grade II (19 patients, 21%). Following muscle relaxation with cisatracurium, the number of patients with Cormack Grade I significantly increased from 43 patients (48%) to 65 patients (72%) (p = 0.0013). Only 1 patient out of 19 patients (5%) improved his Cormack grade from Grade III to Grade I while 16 out 19 patients (84%) improved their Cormack grade from Grade III to Grade II after the use of cisatracurium. The quality of face mask ventilation did not differ with and without muscle relaxants in all patients. Conclusion: The use of cisatracurium in healthy young adults undergoing general elective surgeries with no anticipated difficult endotracheal intubation had no effect on the quality of face mask ventilation despite resulting in a quantifiable improvement in the laryngeal view

Smoking and the risk of mortality and vascular and respiratory events in patients undergoing major surgery

IMPORTANCE The effects of smoking on postoperative outcomes in patients undergoing major surgery are not fully established. The association between smoking and adverse postoperative outcomes has been confirmed. Whether the associations are dose dependent or restricted to patients with smoking-related disease remains to be determined. OBJECTIVE To evaluate the association between current and past smoking on the risk of postoperative mortality and vascular and respiratory events in patients undergoing major surgery. DESIGN Cohort study using the American College of Surgeons National Surgical Quality Improvement Program database. We obtained data on smoking history, perioperative risk factors, and 30-day postoperative outcomes. We assessed the effects of current and past smoking (&gt;1 year prior) on postoperative outcomes after adjustment for potential confounders and effect mediators (eg, cardiovascular disease, chronic obstructive pulmonary disease, and cancer). We also determined whether the effects are dose dependent through analysis of pack-year quintiles. SETTING AND PARTICIPANTS A total of 607 558 adult patients undergoing major surgery in non-Veterans Affairs hospitals across the United States, Canada, Lebanon, and the United Arab Emirates during 2008 and 2009. MAIN OUTCOMES AND MEASURES The primary outcome measure was 30-day postoperative mortality; secondary outcome measures included arterial events (myocardial infarction or cerebrovascular accident), venous events (deep vein thrombosis or pulmonary embolism), and respiratory events (pneumonia, unplanned intubation, or ventilator requirement &gt;48 hours). RESULTS The sample included 125 192 current (20.6%) and 78 763 past (13.0%) smokers. Increased odds of postoperative mortality were noted in current smokers only (odds ratio, 1.17 [95% CI, 1.10-1.24]). When we compared current and past smokers, the adjusted odds ratios were higher in the former for arterial events (1.65 [95% CI, 1.51-1.81] vs 1.20 [1.09-1.31], respectively) and respiratory events (1.45 [1.40-1.51] vs 1.13 [1.08-1.18], respectively). No effects on venous events were observed. The effects of smoking mediated through smoking-related disease were minimal. The increased adjusted odds of mortality in current smokers were evident from a smoking history of less than 10 pack-years, whereas the effects of smoking on arterial and respiratory events were incremental with increased pack-years. CONCLUSIONS AND RELEVANCE Smoking cessation at least 1 year before major surgery abolishes the increased risk of postoperative mortality and decreases the risk of arterial and respiratory events evident in current smokers. These findings should be carried forward to evaluate the value and cost-effectiveness of intervention in this setting. Our study should increase awareness of the detrimental effects of smoking-and the benefits of its cessation-on morbidity and mortality in the surgical setting