American University of Beirut

Epithelioid hemangioendothelioma is a rare vascular tumor originating from vascular endothelial or pre-endothelial cells. We present the case of a 4-month-old male with a rapidly enlarging left zygomatico-orbital tumor causing mass effect on the eye globe. Examination revealed a large, nontender, solid lesion. CT angiography showed no major feeder or intralesional vessels. Complete surgical excision was performed, which was complicated by life-threatening intraoperative bleeding and successfully controlled with electrocautery. Microscopically, tumor cells exhibited varying morphologies. Immunohistochemistry confirmed the diagnosis of epithelioid hemangioendothelioma (positive for CD31 and CD34, negative for CK AE1/AE3). We also highlight 2 similar case reports with life-threatening bleeding complications. Surgeons should be aware of this condition and optimize surgical preparation, including blood products, to manage potential bleeding complications.

The goal of this bibliometric analysis is to summarize publications on the contributions of a higher education university in arts, humanities, and social sciences and evaluate their citation status. Ninety-one publications were indexed in Scopus and WOS databases between 2018 and 2022. All publications appeared in 69 different journals, books, and conferences. About 51.6% of all studies were single-authored. The median number of publications per author was 27.01 ± 48.0 and that of citations was 223.0 ± 764.0. Positive correlations were observed between the journal’s CiteScore and authors’ count with citation number (r² = .625 and .207 respectively; p < .005). Publications written by ≥3 authors with international collaboration received the maximum number of citations (p < .005). Moreover, the mean number of citations for publications written by associate or assistant professors was significantly higher than those composed by their peers (p = .033). Defining the field of arts and humanities remains a difficult exercise, because of its blurry theoretical background. Thus, a repetitive evaluation of its current status remains essential.

In adults, ⁶⁸ Ga-FAP inhibitor ( ⁶⁸ Ga-FAPI) PET/CT outperforms ⁶⁸ Ga-radiolabeled somatostatin analog peptides ( ⁶⁸ Ga PET/CT) and ¹⁸ F-FDG PET/CT in detecting thyroid lesions. This is the case of a 13-year-old boy newly diagnosed with medullary thyroid cancer with high calcitonin level. ⁶⁸ Ga PET/CT revealed the presence of only a primary thyroid lesion. Proven to be superior in detecting metastasis, ⁶⁸ Ga-FAPI PET/CT was performed. The results came out negative for primary and potential metastatic lesions. This case sheds shed light on false-negatives reported in ⁶⁸ Ga-FAPI PET/CT scans in pediatric patients, emphasizing the need for alternate radiotracers when a negative study is met.

Background Lebanon has a high caesarean section use and consequently, placenta accreta spectrum (PAS) is becoming more common. Objectives To compare maternal characteristics, management, and outcomes of women with PAS by planned or urgent delivery at a major public referral hospital in Lebanon. Design Secondary data analysis of prospectively collected data. Setting Rafik Hariri University Hospital (public referral hospital), Beirut, Lebanon. Participants 159 pregnant and postpartum women with confirmed PAS between 2007–2020. Main outcome measures Maternal characteristics, management, and maternal and neonatal outcomes. Results Out of the 159 women with PAS included, 107 (67.3%) underwent planned caesarean delivery and 52 (32.7%) had urgent delivery. Women who underwent urgent delivery for PAS management were more likely to experience antenatal vaginal bleeding compared to those in the planned group (55.8% vs 28.0%, p<0.001). Median gestational age at delivery was significantly lower for the urgent group compared to the planned (34 vs. 36 weeks, p<0.001). There were no significant differences in terms of blood transfusion rates and major maternal morbidity between the two groups; however, median estimated blood loss was significantly higher for women with urgent delivery (1500ml vs. 1200ml, p = 0.011). Furthermore, the urgent delivery group had a significantly lower birth weight (2177.5g vs. 2560g, p<0.001) with higher rates of neonatal intensive care unit (NICU) admission (53.7% vs 23.8%, p<0.001) and perinatal mortality (18.5% vs 3.8%, p = 0.005). Conclusion Urgent delivery among women with PAS is associated with worse maternal and neonatal outcomes compared to the planned approach. Therefore, early referral of women with known or suspected PAS to specialized centres is highly desirable to maximise optimal outcomes for both women and infants.

The connections among fossil fuels, green bonds, and investors have undergone a substantial alteration due to the daunting difficulties posed by climate change risks and energy problems. This study employs quantile connection approaches to the dynamic spillover. The results indicate that extreme quantiles exhibit a higher degree of connectivity compared to the average quantile. In severe circumstances, risk spillover primarily emanates from fossil fuels, whereas investor sentiment (IS) is more vulnerable to the impact of related market hazards. The green bond (GBI) experiences a transition in its function, alternating between being a transmitter and a receiver. To summarise, comprehending the interrelation among these variables offers fresh perspectives for investment decision‐making and policy development to facilitate the shift towards sustainable energy and tackle the climate emergency.

Introduction Lebanon has one of the world's highest waterpipe (WP) consumption rates. Research has documented the effectiveness of implementing pictorial health warning labels (PHWLs) on WP products at encouraging smoking cessation and discouraging youth uptake of smoking. This study aims to gain insight into key informants’ (KIs) views on the issuance, implementation, and compliance of a decree for PHWLs on WP products. Methods Thirteen KIs (policymakers, media, and international/local non-government organization representatives) were interviewed online and asked about potential barriers and facilitators they saw to issuing and implementing a PHWL decree. They were shown examples of PHWLs and asked about processes needed for implementation and compliance. The policy triangle framework (content, actors, context, and process) was used to interpret findings. Results Although there was clear discrepancy and ambiguousness among the KIs’ views regarding process and actors, there was more consensus and clarity around context and content. Challenges to implementation were: (1) multiple sources of production and supply of WP (2) uncertainty regarding the responsible actors for each step, (3) prioritization of a tobacco control decree amidst a political and economic crisis, and (4) challenges to practicality of applying PHWL on the WP given its multi-component nature. Conclusion This research provides an in-depth understanding of KI’s views regarding content, actors, context, and process in relation to the issuance, implementation, and compliance to PHWLs on WP products. Noted challenges require careful consideration if progress is to be made to introduce PHWLs. Implications of the study A growing research base has documented the potential effectiveness of PHWLs on reducing WP consumption. Findings of this study show that implementing PHWLs on WP products requires a distinct understanding of the policy environment and context, as well as content, actors, and processes. Implementing PHWLs on waterpipe tobacco products needs to address the complex nature of waterpipe smoking as a multi-component tobacco use method.

This paper investigates the accounting for defined benefit pension plans in U.S. family firms. Relying on agency theory and the literature on defined benefit pension plans, we test whether the allocation of pension plan assets, the expected rate of return on pension plan assets and the contributions to defined benefit pension plans in family firms are significantly different from those in non‐family firms. Relying on a sample of U.S. firms over the period 2004–2018, we first document that family firms take more risk when allocating their pension plan assets relative to non‐family firms where they allocate a larger (smaller) percentage of pension plan assets in equity (debt) securities. We also show that family firms are more aggressive in setting the expected rate of return on pension plan assets than non‐family firms. However, family firms’ contributions to defined benefit pension plans are comparable to those of non‐family firms. Our findings hold after controlling for the endogeneity in family firms. These findings are important since they provide first hand empirical evidence on the accounting for defined benefit pension plans in family firms. They further shed light over pension plans that serve as a key tool to attract and retain executive talents and make up a significant portion of firms balance’ sheets.

Objective Ophthalmic complications frequently occur after procedures requiring general anaesthesia, but their incidence is widely variable and not well reported in the paediatric population. The aim was to identify the incidence and possible risk factors of postoperative ocular surface complications in a tertiary care centre. Methods and Analysis This is a prospective study for paediatric patients undergoing general anaesthesia. An ophthalmologist performed the ocular examination after surgery. Parameters assessed were tear breakup time, punctate epithelial erosions and corneal abrasions. Multivariate logistic regression model was used to assess risk factors. Results A total of 108 paediatric patients were recruited, 36.1% showed abnormal corneal finding: 32 (29.6%) had decreased tear breakup time, three (2.7%) had punctate epithelial erosions, three (2.7%) had both punctate epithelial erosions and decreased tear breakup time and one (0.9%) was found to have a unilateral corneal abrasion postoperatively. A higher rate of corneal complications was noted with younger age, prolonged surgery and surgery in the head and neck region. Conclusion The rate of postoperative corneal abnormalities in children undergoing general anaesthesia was 36.1%, associated with younger age, prolonged surgery and surgery in the head and neck region.

Introduction. The objective of this study was to describe Do-Not-Resuscitate (DNR) practices in a tertiary-care intensive care unit (ICU) in Saudi Arabia, and determine the predictors and outcomes of patients who had DNR orders. Methods. This retrospective cohort study was based on a prospectively collected database for a medical-surgicalIntensive CareDepartment in a tertiary-care center in Riyadh, Saudi Arabia (1999–2017). We compared patients who had DNR orders during the ICU stay with those with “full code.” The primary outcome was hospital mortality. The secondary outcomes included ICU mortality, tracheostomy, duration of mechanical ventilation, and length of stay in the ICU and hospital. Results. Among 24790 patients admitted to the ICU over the 19-year study period, 3217 (13%) had DNR orders during the ICU stay. Compared to patients with “full code,” patients with DNR orders were older (median 67 years [Q1, Q3: 55, 76] versus 57 years [Q1, Q3: 33, 71], p<0.0001), were more likely to be females (43% versus 38%, p<0.0001), had worse premorbid functional status (WHO performance status scores 4-5: 606[18.9%] versus 1894[8.8%], p<0.0001), higher prevalence of comorbid conditions, and higher APACHE II score (median 28 [Q1, Q3: 23, 34] versus 19 [Q1, Q3: 13, 25], p<0.0001) and were more likely to be mechanically ventilated (83% versus 55%, p<0.0001). Patients had DNR orders were more likely to die in the ICU (67.8% versus 8.5%, p<0.0001) and hospital (82.4% versus 18.1%, p<0.0001). On multivariable logistic regression analysis, the following were associated with an increased likelihood of DNR status: increasing age (odds ratio (OR) 1.01, 95% confidence interval (CI) 1.01–1.02), higher APACHE II score (OR 1.09, 95% CI 1.08–1.10), and worse WHO performance status score. Patients admitted in recent years (2012–2017 versus 2002–2005) were less likely to have DNR orders (OR 0.35, 95% CI 0.32–0.39, p<0.0001). Patients with DNR orders had higher ICU mortality, more tracheostomies, longer duration of mechanical ventilation and length of ICU stay compared to patients with with “full code” but they had shorter length of hospital stay. Conclusion. In a tertiary-care hospital in Saudi Arabia, 13% of critically ill patients had DNR orders during ICU stay. This study identified several predictors of DNR orders, including the severity of illness and poor premorbid functional status.

Background To compare the outcomes of two types of tarsoconjunctival pedicle flaps for reconstruction of large lower eyelid defects. Methods Retrospective medical record review of consecutive patients who underwent centrally-based or laterally-based tarsoconjunctival pedicle transconjunctival flap for lower eyelid reconstruction for defects greater than 50% of the lid margin. Full thickness skin grafts were used for anterior lamellar reconstruction in all cases. The primary outcome measure was eyelid position, function and satisfactory cosmesis. Results Forty-three patients were identified. Twenty-six patients underwent reconstruction with a centrally-based tarsoconjunctival pedicle flap; 17 patients underwent reconstruction with a laterally-based tarsoconjunctival pedicle flap. The average size of the lid defect was 77.7% (range 50-100%) in the central group and 75% (range 50-100%) in the lateral group (p=0.604). Mean follow up time was 61.5 weeks in the central group and 46.6 weeks in the lateral group (p=0.765). After division of the flap and during follow up, 27% of the centrally based group required revisional surgery with none in the laterally based group (p=0.03). 100% of the patients with centrally based flaps required second staged division of flap, whereas only 52% of patients with a laterally based flaps underwent second staged flap division. (p<0.001) Conclusion Outcome suggests that for reconstruction of large lower lid defects requiring lid sharing procedures, both centrally and lateral-based procedures have equivalent functional outcome. However, the laterally based group has less need for revisional procedures and may not need a second stage division of the flap.

This article investigates the effect of global oil and wheat prices, and local price shocks on the real price of wheat flour in Lebanon. We estimate a structural vector autoregressive model with exogenous variables (SVARX) using Bayesian methods. We then compute the impulse response functions and find that global commodity price shocks play a trivial role. Meanwhile, local gasoline price and wheat flour price‐specific shocks trigger large increases in the Lebanese wheat flour price on impact. Furthermore, since 2020, local gasoline price and wheat flour price‐specific shocks have contributed the most to the historical variation in the Lebanese wheat flour price.

Background Developing countries have a significantly higher incidence of breast cancer in patients younger than 40 years as compared to developed countries. This study aimed to examine if young age at diagnosis is an independent prognostic factor for worse survival outcomes in breast cancer as well as the effect of age on Disease-free survival (DFS) and local recurrence free survival (LRFS) after adjusting for various tumor characteristics, local and systemic treatments. Methods This is a secondary analysis of prospective cohort of patients from two existing databases. We identified patients with breast cancer aged 40 years or less and we matched them to those older than 40 years. We also matched based on stage and molecular subtypes. In cohort 1, we matched at a ratio of 1:1, while in cohort 2 we matched at a ratio of 1:3. Results In cohort 1, Disease-free survival (DFS) at 5 years was significantly shorter for those younger than 40 years (75.6% and 92.7% respectively; p < 0.03). On multivariate analysis, only chemotherapy was found to be significant, while age was not found to be an independent predictor of prognosis. Local recurrence free survival at 5 years was similar between both age categories. Only hormonal therapy is a significant predictor for LRFS at 5 years. In the second cohort, DFS and LRFS at 3 years were similar between those younger and those older than 40 years. On multivariate analysis, no factor including age was found to be an independent predictor of prognosis. Conclusion Data in the literature is controversial on the effect of young age on breast cancer prognosis. Our findings could not demonstrate that age is an independent prognostic factor in our population. There is a need for outcomes from larger, prospective series that have longer follow-ups and more data from our region.

Background: Migraine is a prevalent episodic brain disorder known for recurrent attacks of unilateral headaches, accompanied by complaints of photophobia, phonophobia, nausea, and vomiting. Two main categories of migraine are migraine with aura (MA) and migraine without aura (MO). Main body: Early twin and population studies have shown a genetic basis for these disorders, and efforts have been invested since to discern the genes involved. Many techniques, including candidate-gene association studies, loci linkage studies, genome-wide association, and transcription studies, have been used for this goal. As a result, several genes were pinned with concurrent and conflicting data among studies. It is important to understand the evolution of techniques and their findings. Conclusions: This review provides a chronological understanding of the different techniques used from the dawn of migraine genetic investigations and the genes linked with the migraine subtypes.

Errors in pathology are rare but may have disastrous consequences. They happen at any of the three stages of specimen handling: the pre-analytical stage before the specimen reaches the lab, the analytical stage when the specimen is in the lab with the pathologist for processing and interpretation, and the post-analytical stage when the result is officially reported. In this chapter, we will briefly go over the different steps a specimen goes through before reaching the lab, namely patient identification, communication between clinician and pathologist, clinical history, tissue identification and orientation, tissue preservation, and tissue transportation. We will also discuss the errors that can occur during this process and what can be done to minimize and prevent them.

The high rate of utilization of cardiac implantable electronic devices (CIEDs) and the high stakes in case of malfunction makes it crucial that we understand and optimize the perioperative management of CIEDs. Several professional societies have addressed the topic. The function of CIED can be altered by electromagnetic interference (EMI), potentially causing iatrogenic adverse outcomes. There are several sources of EMI in the operating room. A comprehensive preoperative assessment for patients with CIED undergoing elective surgery should be performed. Device interrogation and appropriate reprogramming, if necessary, should be done before the surgical intervention. Reprogramming can be performed using a reprogramming machine or through magnet application in certain conditions. Several factors should be considered during the intraoperative period that are centered on continuous monitoring and preparedness for emergencies. Transcutaneous/defibrillator pads should be placed on the patient during the surgical procedure. Postoperative management includes reactivation of CIED and appropriate device interrogation to check for any malfunction during or following the surgical procedure.

The operating room (OR) is a complex and challenging workplace, and OR personnel face various hazards constantly. Traffic, attire, and distraction are all an integral part of the OR and play a crucial role in ensuring a safe and efficient working environment. The surgical suite is divided into three designated areas: the unrestricted, the semi-restricted, and the restricted. In principle, as we progress from the unrestricted to the restricted areas, regulations regarding the traffic of personnel and material, the appropriate attire, and the environmental control become stricter. In this chapter, we present the role of traffic as a predisposing factor for surgical site infections (SSIs). Then we present the literature’s controversies regarding our attire policies and summarize the current recommendations regarding attire in the OR. Increased OR traffic and inappropriate attire could aggravate SSI rates. Following the current guidelines could help reduce SSIs. Finally, we demonstrate how distractions in the OR could compromise surgical care quality and jeopardize patient safety. Surprisingly, most of our current practices reflect a continuation of historic practices rather than evidence-based ones. Nevertheless, current guidelines advocate for the enforcement of these practices, probably until high-quality evidence suggests otherwise. Therefore, myth and reality will most likely continue to coexist for the imminent future.

Management of the difficult airway is guided by expert algorithms and consensus. Maintenance of adequate patient oxygenation is the first priority. The best indicator that a patient may be easily ventilated or intubated is a history of prior success. In the absence of prior records, the best available method to predict difficult mask ventilation is airway examination and a review of comorbid conditions. Whenever both mask and supraglottic airway device ventilation are impossible, intubation should be attempted by a skilled physician using a familiar technique to have the greatest likelihood of success. Repeated attempts at intubation or ventilation using supraglottic airway devices should be limited as they may result in edema, bleeding, and deterioration of the airway condition. The decision to try awakening the patient or using emergency invasive airway access should be considered promptly if the airway is not secured.

Venous thromboembolism (VTE) is a common but serious medical complication associated with high perioperative morbidity and mortality. VTE usually comprises both deep vein thrombosis (DVT) and pulmonary emboli (PE). Prophylaxis against VTE is of utmost importance in the perioperative setting and is considered a patient-safety measure in most mandates and quality initiatives. VTE prophylaxis can be achieved using mechanical or pharmacological interventions. Here we discuss the different types of thromboprophylaxis that can be used in surgical patients and the proper patient- and procedure-related recommendations.

Surgical patients treated with anticoagulants and/or antiplatelets require a clear plan regarding the management of their hemostasis-altering medications throughout the perioperative period. These therapies are often prescribed to treat morbid conditions such as deep vein thrombosis and cardiac or cerebral embolic events, as well as prevention of embolic events in the presence of cardiac arrhythmias, prosthetic valves, or risk factors for deep vein thrombosis or pulmonary embolism. Withholding such medications is not without risk, which varies depending on the primary condition for which the medications are prescribed. On the other hand, maintaining such therapies may exacerbate the risk of perioperative bleeding. The management of medications in the perioperative period does not only concern drugs-related coagulation hemostasis. Preexisting hypertension imposes the challenge of managing antihypertensive medications. These patients are more likely to experience intraoperative blood pressure and hemodynamic fluctuations that may lead to myocardial injury. Many areas of controversy remain regarding the optimal management of perioperative medications. International guidelines offer an evidence-based framework and can help the clinician navigate through these complex clinical dilemmas.