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Background: Pancreaticoduodenectomy (PD) remains the only curative option for patients with pancreatic adenocarcinoma (PDAC). Infectious complications (IC) can negatively impact patient outcomes and delay adjuvant therapy in most patients. This study aims to determine IC effect on overall survival (OS) following PD for PDAC., Study Design: Patients who underwent PD for PDAC between 2010 and 2020 were identified from a single institutional database. Patients were categorized into two groups based on whether they experienced IC or not. The relationship between postoperative IC and OS was investigated using Kaplan-Meier and Cox-regression multivariate analysis., Results: Among 655 patients who underwent PD for PDAC, 197 (30%) experienced a postoperative IC. Superficial wound infection was the most common type of infectious complication (n = 125, 63.4%). Patients with IC had significantly more minor complications (Clavien-Dindo [CD] < 3; [59.4% vs. 40.2%, p < 0.001]), major complications (CD ≥ 3; [37.6% vs. 18.8%, p < 0.001]), prolonged LOS (47.2% vs 20.3%, p < 0.001), biochemical leak (6.1% vs. 2.8%, p = 0.046), postoperative bleeding (4.1% vs. 1.3%, p = 0.026) and reoperation (9.6% vs. 2.2%, p < 0.001). Time to adjuvant chemotherapy was delayed in patients with IC versus those without (10 vs. 8 weeks, p < 0.001). Median OS for patients who experienced no complication, noninfectious complication, and infectious complication was 33.3 months, 29.06 months, and 27.58 months respectively (p = 0.023). On multivariate analysis, postoperative IC were an independent predictor of worse OS (HR 1.32, p = 0.049)., Conclusions: IC following PD for PDAC independently predict worse oncologic outcomes. Thus, efforts to prevent and manage IC should be a priority in the care of patients undergoing PD for PDAC., (© 2024 Wiley Periodicals LLC.)

Purpose: The aim of this study is to analyze obstetrical and reproductive health parameters in Lebanon from 2015 until 2018 in the setting of the Syrian refugee influx in order to evaluate potential risks and provide a management plan to improve outcomes., Description: Data from the Lebanese Ministry of Public Health (LMPH) on all obstetrical deliveries that occurred in Lebanon between 2015 and 2018 was screened and analyzed. Number and mode of delivery as well as maternal and neonatal outcomes were included. Joinpoint regression analysis was used for trends of selected parameters. Independent two-sample t-tests were used for comparisons., Assessment: Women of non-Lebanese nationality residing in Lebanon had a significantly greater number of total deliveries (p-value < 0.001), vaginal deliveries (p-value = 0.002), cesarean sections (p-value = 0.02). When looking at delivery trends from 2015 to 2018, Lebanese women had a significant decrease in total number of deliveries (p-value < 0.001) and vaginal deliveries (p-value < 0.001)., Conclusion: Total number of deliveries and cesarean sections is on the rise in Lebanon. Cesarean section practice should be audited by the LMPH and the Lebanese Order of Physicians (LOP). Local and international agencies should prioritize the implementation and management of family planning facilities in refugee hosting countries., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To compare the rate of postoperative 30-day complications between laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD)., Background: Previous studies suggest that minimally invasive pancreaticoduodenectomy (MI-PD)-either LPD or RPD-is noninferior to open pancreaticoduodenectomy in terms of operative outcomes. However, a direct comparison of the two minimally invasive approaches has not been rigorously performed., Methods: Patients who underwent MI-PD were abstracted from the 2014 to 2019 pancreas-targeted American College of Surgeons National Sample Quality Improvement Program (ACS NSQIP) dataset. Optimal outcome was defined as absence of postoperative mortality, serious complication, percutaneous drainage, reoperation, and prolonged length of stay (75th percentile, 11 days) with no readmission. Multivariable logistic regression models were used to compare optimal outcome of RPD and LPD., Results: A total of 1540 MI-PDs were identified between 2014 and 2019, of which 885 (57%) were RPD and 655 (43%) were LPD. The rate of RPD cases/year significantly increased from 2.4% to 8.4% ( P =0.008) from 2014 to 2019, while LPD remained unchanged. Similarly, the rate of optimal outcome for RPD increased during the study period from 48.2% to 57.8% ( P <0.001) but significantly decreased for LPD (53.5% to 44.9%, P <0.001). During 2018-2019, RPD outcomes surpassed LPD for any complication [odds ratio (OR)=0.58, P =0.004], serious complications (OR=0.61, P =0.011), and optimal outcome (OR=1.78, P =0.001)., Conclusions: RPD adoption increased compared with LPD and was associated with decreased overall complications, serious complications, and increased optimal outcome compared with LPD in 2018-2019., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Calcaneal apophysitis is an overuse injury in pediatric patients that causes heel pain and reduction in function. The aim of this study is to explore this condition and offer medical insight into its presentation and symptomatology, along with current treatment options., Methods: We explored PubMed/Medline for studies involving calcaneal apophysitis in pediatric patients. The search included all articles published from database inception until June 1, 2021. We only included articles published in English. Clinical information and demographics extracted from the reported studies were analyzed and assessed., Results: Only 28 studies met our criteria, with a total of 1,362 cases. Of the cases reported, 973 affected boys (71.4%). Presentation was bilateral in 589 cases (43.2%) and unilateral in 433 cases (31.8%). Radiographic imaging was used for the diagnosis of 358 cases (26.3%). All reported treatment modalities were conservative, and these included physical therapy and rest, kinesiotherapy and taping, and orthotic devices. A total of 733 cases (53.7%) reported improved outcomes,32 cases (2.3%) reported no improvement, and the remainder of cases did not report prognostic outcomes (44%)., Conclusions: Calcaneal apophysitis is an overuse disease commonly found in the pediatric population. Educating parents and coaches with regard to its symptomatology, etiology, and treatment is essential to diagnose the condition earlier and provide better outcomes.

Introduction: Conflicting reports exist about the effect obesity has on adverse postoperative surgical outcomes after distal pancreatectomy (DP). The aim of this study is to explore the role of obesity in terms of morbidity and pancreas-specific complications following DP for pancreatic ductal adenocarcinoma (PDAC)., Methods: All patients who underwent DP at a single institution over 10 y were analyzed (2009-2020). Patients were categorized as nonobese (body mass index [BMI] < 30 kg/m 2 ) and obese (BMI ≥ 30 kg/m 2 ). Independent predictors of adverse postoperative outcomes were calculated using multivariate logistic regression models. Overall survival was assessed using Kaplan-Meier survival analysis., Results: Of the 178 patients included, 58 (32.5%) were obese. Clinically relevant postoperative pancreatic fistula (CR-POPF) formation rate was significantly higher in the obese group (20.6% versus 7.5%, P value = 0.011). We did not identify any significant difference between obese and nonobese patients in median overall survival (30.2 mon versus 28.9 mon, P value = 0.811). On multivariate binary logistic regression analysis, BMI ≥ 30 was an independent predictor of morbidity (any complication) and CR-POPF formation after DP for PDAC., Conclusions: Obesity is associated with a significantly increased risk for CR-POPF in patients undergoing DP for PDAC. Obesity should be considered as a variable in fistula risk calculators for DP., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Pancreaticoduodenectomy (PD) remains a complex surgical procedure with infectious complications affecting nearly 50% of patients. Patients who undergo biliary drainage with stent placement prior to neoadjuvant treatment (NAT) reportedly have higher infection rates following PD. The aim of the current study is to evaluate the differences in postoperative infectious complication rates based on the duration of post operative prophylactic antibiotics in patients with indwelling metal biliary stent who had NAT., Methods: A retrospective institutional pancreatic cancer database was queried for patients who had a metal biliary stent placed prior to NAT initiation, followed by subsequent PD between 2014 and 2021. Duration of postoperative prophylactic antibiotics was defined as short (SC: ≤ 24 h) or extended (EC: > 24 h-7 days). The primary outcome of interest was surgical site infection (SSI)., Results: Two hundred and ninety-five (n = 295) patients were identified of which the majority (n = 205, 69.5%) received a short course of antibiotics postoperatively. Baseline characteristics were similar between the two cohorts including age, sex, BMI, and comorbidity index. EC patients received more NAT cycles (4 vs. 3, p < 0.001) and underwent an open PD more frequently (61.8% vs. 41.0%, p < 0.001). SSI occurred in 64 (21.7%) patients; SC cohort: 54, 26.3% vs. EC cohort:10, 11.1%, (p = 0.003). Additionally, the SC cohort demonstrated a higher incidence of major complications (Clavien-Dindo ≥ 3: 51 [24.9%] vs. 13 [14.4%], p = 0.045). On the logistic regression model examining factors associated with SSI, higher BMI (continuous variable) was associated with increased odds of SSI (OR: 1.05 [95%CI: 1.00, 1.10, p = 0.040), while EC was protective (OR: 0.36 [95%CI: 0.17, 0.75], p = 0.007)., Conclusions: These data suggest that an extended course of perioperative antibiotic correlates with reductions in SSI and major morbidity following PD in patients with a metallic biliary stent placed prior to NAT course. These results require validation in a future randomized clinical trial examining a larger cohort of patients with further emphasis on the types of perioperative antibiotics administered., (© 2023. The Society for Surgery of the Alimentary Tract.)

Background: Activities and inhibition of the Renin-Angiotensin-Aldosterone System (RAAS) may affect the survival of resected pancreatic ductal adenocarcinoma (PDAC) patients METHOD: A single-institution retrospective analysis of resected PDAC patients between 2010 and 2019. To estimate the effect of angiotensin system inhibitors (ASIs) on patient survival, we performed Kaplan Meier analysis, Cox Proportional Hazards model, Propensity Score Matching (PSM), and inverse probability weighting (IPW) analysis., Results: 742 patients were included in the analysis. The average age was 67.0 years, with a median follow-up of 24.1 months. The use of ASI was associated with significantly longer overall survival in univariate (p = 0.004) and multivariable (HR = 0.70 [0.56-0.88],p = 0.003) adjusted analysis. In a propensity score-matched cohort of 400 patients, ASI use was again associated with longer overall survival (p = 0.039). Lastly, inverse probability weighting (IPW) analysis suggested that the use of ASI was associated with an average treatment effect on the treated (ATT) of HR = 0.68 [0.53-0.86],p = 0.002) for overall survival., Conclusion: In this single-institution retrospective study focusing on resected PDAC patients, the use of ASI was associated with longer overall survival in multiple statistical models. Prospective clinical trials are needed before routine clinical implementation of ASI as an adjuvant to existing therapy can be recommended., (Copyright © 2022 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Hepatopancreaticobiliary (HPB) diseases carry high morbidity despite efforts aimed at their reduction. An assessment of their trial characteristics is paramount to determine trial design adequacy and highlight areas for improvement. As such, the aim of this study is to assess HPB surgery trial characteristics, summarize logistic, financial, and practical reasons behind early discontinuation, and propose potential interventions to prevent this in the future., Methods: All clinical trials investigating HPB surgery registered on ClinicalTrials.gov from October 1st, 2007 (inclusive), to April 20th, 2021 (inclusive), were examined. Trial characteristics were collected including, but not limited to, study phase, duration, patient enrollment size, location, and study design. Peer-reviewed publications associated with the selected trials were also assessed to determine outcome reporting., Results: A total of 1776 clinical trials conducted in 43 countries were identified, the majority of which were conducted in the USA. Of these trials, 32% were reported as "completed" whereas 12% were "discontinued." The most common cause of trial discontinuation was low accrual, which was reported in 37% of terminated studies. These resulted in 413 published studies. Most trials had multiple assignment, randomized, or open-label designs. Treatment was the most common study objective (73%) with pharmacological therapy being the most commonly studied intervention., Conclusions: The main reasons for early discontinuation of clinical trials in HPB surgery are poor patient recruitment and inadequate funding. Improved trial design, recruitment strategies and increased funding are needed to prevent trial discontinuation and increase publication rates of HPB surgery clinical trials., (© 2022. The Society for Surgery of the Alimentary Tract.)

Background: International medical graduates (IMGs) have been a critical part of the USA healthcare in the past 30 years, especially in small rural and poor counties. However, little to no publications are present on the distribution of these IMGs across general surgery residency programs., Methods: All freely accessible information on current residents in accredited general surgery residency programs within the USA with at least a 5-year history was explored for IMGs in the current roster using the AMA residency and fellowship database in 2020. Demographic and geographic data were summarized., Results: A total of 230 general surgery residency program were included. Programs were distributed among 46 (92%) states. Of a total 6304 categorical general surgery residents, 573 (9%) were IMGs. Florida (USA) had the highest total number of current IMG general surgery residents with 64. The highest percentage of current IMG residents was found in Maryland (USA) with 31%. IMGs obtained their medical degrees from 76 different countries worldwide. Grenada was the country with the highest origin of IMGs with 77 residents. Central/North America had the highest origin of IMGs with 217 (38%)., Conclusions: IMGs make up a small portion of current general surgery residents in USA programs. Some states host more IMGs than others. Particular countries have contributed more IMGs than others. More research is needed to the challenges facing IMGs and come up with novel solutions for them.

Background: The Model End-Stage Liver Disease (MELD) has been widely used to predict the mortality and morbidity of various surgical procedures. We aimed to assess the impact of preoperative MELD score on adverse 30-day postoperative outcomes following gastrectomy., Methods: Patients who underwent elective, non-emergent gastrectomy were identified from the ACS NSQIP 2014-2019 database. Patients were categorized according to a calculated MELD score. The primary outcomes of this study were the 30-day overall complications and major complication rates following gastrectomy., Results: Compared to MELD <11, patients with MELD ≥11 had significantly higher rates of mortality, any complication, and major complication. MELD score ≥11 was significantly associated with any complication (OR 1.73, p = 0.011) and major complications (1.85, p = 0.014) on multivariate analysis., Conclusions: MELD score ≥11 was associated with poorer outcomes in patients undergoing gastrectomy compared to lower MELD scores., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The use robotics in surgery is gaining momentum. This approach holds substantial promise in pancreas surgery. Robotic surgery for pancreatic lesions and malignancies has become well accepted and is expanding to more and more center annually. The number of centers using robotics in pancreatic surgery is rapidly increasing. The most studied robotic pancreas surgeries are pancreaticoduodenectomy and distal pancreatectomy. Most studies are in their early phases, but they report that robotic pancreas surgery is safe feasible. Robotic pancreas surgery offers several advantages over open and laparoscopic techniques. Data regarding costs of robotics versus conventional techniques is still lacking. Robotic pancreas surgery is still in its early stages. It holds promise to become the new surgical standard for pancreatic resections in the future, however, more research is still needed to establish its safety, cost effectiveness and efficacy in providing the best outcomes., (© 2021. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background: The two approaches for performing cholecystectomy are open and laparoscopic ones. This study aims to characterize national trends of cholecystectomies in the United States (US) and determine differences by approach, age group, primary payer, teaching status and location of healthcare center., Methods: Retrospective analysis of patients undergoing cholecystectomy was done using the US National Inpatient Sample from 1997 to 2011. Trends in open and laparoscopic cholecystectomy were analyzed, as well as comparison between age groups, primary payer, location and teaching status of hospitals operations were performed at., Results: Around 6 million cholecystectomies performed from 1997 to 2011. The laparoscopic approach was significantly more common than the open (P<0.001). A significant decrease in open cholecystectomies is seen since 1997. Age group of 65-84 had significantly the most cases in the open approach (P<0.001), while in laparoscopic the 18-44 age group had the significantly highest amount (P<0.001). Medicare covered the most cases for open, while private insurance covered the most in the laparoscopic approach. Most cases were performed in urban, private non-profit, non-teaching hospitals in both groups. In the laparoscopic group the South had a significantly higher (P<0.001) number of cases compared to all other US regions., Conclusions: Cholecystectomies remained constant from 1997 to 2011. The number of open cholecystectomies decreased over time in favor of laparoscopic ones. More funding should be given to private non-teaching hospitals as they perform the majority of cholecystectomies nationwide. Better management of cholecystectomy risk factors is needed in the South.

Background: The use of ACS-NSQIP has increased in pancreatic surgery (PS) research. The aim of this study is to critically appraise the methodological reporting of PS publications utilizing the ACS-NSQIP database., Study Design: PubMed was queried for all PS studies employing the ACS-NSQIP database published between 2004 and 2021. Critical appraisal was performed using the JAMA-Surgery Checklist, STROBE Statement, and RECORD Statement., Results: A total of 86 studies were included. Median scores for number of fulfilled criteria for the JAMA-Surgery Checklist, STROBE Statement, and RECORD Statement were 6, 20, and 6 respectively. The most commonly unfulfilled criteria were those relating to discussion of missed data, compliance with IRB, unadjusted and adjusted outcomes, providing supplementary/raw information, and performing subgroup analyses., Conclusion: An overall satisfactory reporting of methodology is present among PS studies utilizing the ACS-NSQIP database. Areas for improved adherence include discussing missed data, providing supplementary information, and performing subgroup analysis. Due to the increasing role of large-scale databases, enhanced adherence to reporting guidelines may advance PS research., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Strength and power constitute vital predictors for an individual's quality of life and athletic performance. Measurement of these two parameters is very important in the world of sports science and medicine and necessitates a high level of accuracy and reliability. Several tests are used to measure strength and power, including the isometric maximal voluntary contraction test, the 1-repetition maximum test, and the Wingate test, as well as other tests that target upper and lower limbs. The unique characteristics present in each of these tests entail a subsequently unique mode of application during the process of rehabilitation. This helps athletic trainers and medical personnel evaluate recovery and decide on a potential return to sport. A comprehensive holistic approach that includes multiple testing, psychosocial assessment, and a gradual return to activity is best to achieve promising outcomes and preinjury athletic levels., Level of Evidence: V, expert opinion., (© 2021 The Authors.)

Background: Multiple myeloma (MM) is a common hematological malignancy in aging populations. This study aims to inspect the trends from 2005 to 2016 and future projections of MM in Lebanon and to compare its incidence-rates to other MENA and non-MENA countries., Methods: The data concerning MM cases over the studied period was extracted from the National Cancer Registry (NCR) of Lebanon. The online database "Cancer Incidence in Five Continents" was screened and data of other countries were collected. The age-specific and age-standardized incidence rates (ASR(w)) were computed and analyzed using Joinpoint regression. 10 year projections were predicted by employing a logarithmic model., Results: During the time period 2005-2016, MM was significantly more common in males. Both genders had a cancer peak in patients older than 75 years. MM demonstrated a significantly increasing trend in both genders over the 12 years of study. Compared to other countries in the MENA region, Lebanon ranked first in females and second in males, while it came among the lowest when compared to randomly selected developed countries from non-MENA regions. Projecting to 2026, incidence rates of MM in Lebanon are expected to rise in both males and females., Conclusion: Incidence of MM in Lebanon is continually rising. The elderly population, especially males, is much more affected than the younger one. Different risk factors, specifically obesity and toxic exposures, can explain the escalating burden of MM among the population. A collaboration of efforts between the government and health organization is expected for an effective disease control., (Copyright © 2022. Published by Elsevier Ltd.)

Objective : Mixed-Martial-Arts (MMA) has witnessed a rapid growth over the recent years. This study aims to explore the patterns and trends of head injuries in MMA. Design : Descriptive epidemiological study. Setting : Ringside physician reports of the Ultimate Fighting Championship (UFC) fights between 2016 and 2019 (inclusive) were screened. Data were extracted from the Nevada State Athletic Commission (NSAC) database. Play-by-play video analysis was also conducted. Participants : UFC fighters involved in fights sanctioned by the NSAC, between 2016 and the end of 2019 (N = 816). Independent variables : Sex, location of head injury, type of head injury, injury mechanism, number of significant head strikes, type of finish, and weight division. Main outcome measures : Head injury rates were calculated. A one-way analysis of variance (ANOVA) was used to explore any statistically significant differences between injury rates of different locations, types, and types of finishes. An independent t-test was used to determine whether any significant differences existed between the two sexes, and a Joinpoint regression analysis was used to determine the statistical significance of the trends of head injury rates across different weight divisions. P-values <0.05 were considered significant (95% CI). Results : A total of 288 head injuries in 408 fights were recorded during our study period. Head injury rate constituted 35 injuries per 100 athletic-exposures (AE) in sanctioned fights. Traumatic brain injuries (TBI) were the most common type of injury, with a rate of 16 per 100AE, significantly greater than that of fractures (p = 0.003). Males had a head injury rate of 37 per 100AE, higher than that of females which was 23 per 100AE. Technical Knockout (TKO)/ Knockout(KO) was the type of finish with the highest rate of head injuries, significantly greater than that of decision or submission (p < 0.001). In general, head injury rates were higher as weight divisions increased. Conclusion : Head injuries are prevalent in MMA. Preventive measures need to be implemented to ensure fighter safety and limit injury risk.

Background: There is a scarcity of epidemiological studies on back injuries in Major League Baseball (MLB). In our study, we explore all back related injuries in MLB from 2010 to 2016 (inclusive) with the aim to help better understand these injuries, assess their risks, and improve their prevention policies., Methods: The transaction lists from the MLB website were screened for back injuries from 2010 through 2016. Only players who were placed on the disabled list (DL) for one or more days due to back-related injury were included in our study. Our database included the player's position, team, injury location, injury type, days spent on the DL and month of injury occurrence., Results: Two hundred fifty-four back injuries, an equivalent of 7% of all injuries, were recorded between 2010 and 2016 (inclusive). These injuries increased from 2010 to 2016. Back related injuries were found to place players on the disabled list for around 54 days. Injuries were recorded mostly during April, and strain was significantly greater than any other type of injury (P value <0.001)., Conclusions: Back injuries are prevalent in the MLB. Better understanding of the trends and patterns of these injuries will help in establishing better prevention policies.

Abstract: Locally advanced and borderline resectable pancreatic cancers are being increasingly recognized as a result of significant improvements in imaging modalities. The main tools used in diagnosis of these tumors include endoscopic ultrasound, computed tomography, magnetic resonance imaging, and diagnostic laparoscopy. The definition of what constitutes a locally advanced or borderline resectable tumor is still controversial to this day. Borderline resectable tumors have been treated with neoadjuvant therapy approaches that aim at reducing tumor size, thus improving the chances of an R0 resection. Both chemotherapy and radiotherapy (solo or in combination) have been used in this setting. The main chemotherapy agents that have shown to increase resectability and survival are FOLFORINOX (a combination of folinic acid, fluorouracil, irinotecan, and oxaliplatin) and gemcitabine-nab-paclitaxel. Surgery on these tumors remains a significantly challenging task for pancreatic surgeons. More studies are needed to determine the best agents to be used in the neoadjuvant and adjuvant settings, biologic markers for prognostic and operative predictions, and validation of previously published retrospective results., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

The use of liquid biopsies is a relatively new tool in diagnosis and management of gastrointestinal cancers and is actively being investigated. Liquid biopsies have become extremely popular in cholangiocarcinoma and pancreatic cancer research. With more prospective trials using this tool for early diagnosis, liquid biopsies may become an important part of cancer management., Competing Interests: Conflict-of-interest statement: The author does not report any conflict of interest. The author did not receive any funding., (©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Hepatic epithelioid hemangioendothelioma (HEH) is a rare tumor that can affect multiple organs. Little is known about the pathophysiology, clinical course and management of this disease. The aim of this study is to determine survival rates and elucidate the role of various prognostic factors and therapeutic modalities as compared to surgery on patients with HEH., Methods: A retrospective analysis on patients diagnosed with HEH between 2004 and 2016 was performed utilizing the SEER database. Kaplan-Meier curves were constructed to determine overall and cancer-specific survival, and the log-rank test was used to compare between groups. To explore prognostic factors and treatment outcomes, univariable and multivariable Cox proportional hazard models were developed., Results: A total of 353 patients with HEH (median age: 50.4 years) were identified. The most common surgery performed was liver resection (90.8%). One-year OS in the surgical group and non-surgical group was 86.6% and 61.0%, respectively, while 5-year OS was 75.2% and 37.4%, respectively. On multivariable analysis, surgery emerged as a favorable prognostic factor [HR (95%CI): 0.404 (0.215-0.758) p value = 0.005]. Age > 65 years [HR (95%CI): 2.548 (1.442-4.506) p value = 0.001] and tumor size > 10 cm [HR (95%CI): 2.401 (1.319-4.37) p value = 0.004] were shown to be poor survival prognostic factors., Conclusion: HEH is a rare disease that is poorly understood. Surgical intervention is associated with improved survival rates. Multicenter prospective collaborations are needed to improve our limited knowledge about this neoplasm and determine the optimal treatment strategy., (© 2021. Société Internationale de Chirurgie.)

Sever's disease is an underreported prevalent pediatric condition that causes heel pain in children worldwide. It is often described as an overuse injury that can present with either unilateral or bilateral heel pain. Even though the exact mechanism of injury is unknown, it is often thought it involves repetitive stress and pressure on the calcaneal growth plate. Diagnosing Sever's disease mainly relies on a thorough clinical investigation and physical examination, with a positive squeeze test usually sufficient to establish diagnosis. Nevertheless, radiographic imaging can help exclude other differential diagnoses. Therapeutic options of Sever's disease are mostly conservative, and these include rest, physical therapy, kinesiotherapy, and orthoses. Educating parents and coaches on the symptomatology and presentation of Sever's disease is pivotal for the establishment of efficient preventive interventions and earlier diagnoses. This study presents a case of a pediatric patient with Sever's disease and offers medical insight into the diagnostic, clinical, pathologic, and therapeutic characteristics of this condition, in light of the current existing literature., (© 2021 Marshfield Clinic Health System.)

Background: The Internet has become a central source of information on health-related issues. The aim of this study is to assess the quality and readability of online information present on the Whipple surgical procedure by applying recognized scoring tools., Methods: A search using the top three online search engines (Google, Bing and Yahoo) was conducted in July 2020. Websites were classified as academic, physician, commercial or unspecified. The quality of information was assessed using the JAMA and DISCERN assessment instruments and presence of a HONcode seal. Readability was assessed using the Flesch Reading Ease Score (FRES)., Results: A total of 34 unique sources were included in our study. The average JAMA and DISCERN scores of all websites were 2.22 ± 0.48 and 47.28 ± 1.17, respectively, with a median of 1.9 (range 0-4) and 47 (range 18-71), respectively. Website classification distribution was 38% academic, 18% commercial, 9% unspecified, and 1% from physician-based websites. Physician websites had the highest JAMA score with a mean of 3 ± 0.46. Unspecified websites had the highest DISCERN score with a mean of 54.60 ± 1.09. Only 3 websites had the HONcode seal. Physician websites had a significantly higher JAMA mean score than academic websites (p-value = 0.004). Readability was difficult and is on the level of university students., Conclusion: The results of this study show a poor quality of online information present on the Whipple surgery. Academic and physician websites need to improve the quality of their websites on the procedure. More HONcode-certified websites are needed as they are the best source for information on this operation.

The outbreak of the novel coronavirus disease in 2019 (COVID-19) caused a plethora of challenges worldwide and tested healthcare systems across the six continents. Lebanon had recently faced harsh political and economic crises. We aim to describe the effect of COVID-19 on an already crisis-stricken country. A descriptive analysis of the burden of COVID-19 pandemic on Lebanon was performed. Relevant data on COVID-19 was retrieved from the Lebanese Ministry of Public Health from February 21 till June 13th, 2020. Results obtained were analyzed and a literature review was performed. 1422 confirmed COVID-19 cases were identified and reported in Lebanon by June 13th, 2020, comprising an incidence rate of 208/million persons. There has been a total of 31 deaths thus far, with a reported death rate of 5/million persons. The age group with the highest number of cases was 20-29 years. Beirut was the district with the highest number of cases (18%). The COVID-19 crisis has impacted the country on a multifactorial level. COVID-19 could not have come at a worse time for Lebanon. The country is on brink of bankruptcy, the healthcare system is struggling for survival and the government is striving to regain the trust of the population.

Purpose: Gallbladder cancer (GBC) is the most common malignancy of the biliary tract. The median survival of the disease is around 6 months. In this study, we explore clinical trials related to non-resectable GBC, determine the shortcomings leading to the lack of development of new treatment, and shed light on possible areas of improvement., Methods: On April 20, 2019 the authors completed a search on ClinicalTrials.gov for all therapeutic and interventional clinical trials involving non-resectable GBC, without any limits on date or location. Trial characteristics such as duration, phase, sample size, and whether a publication was produced were collected and analyzed., Results: Sixty-two trials met our selection criteria. The average duration of trials was 5 years. Trials were conducted in 8 different countries: most of them in North America (USA and Canada). About 88% of trials were in early phases (I, I/II, and II) and 85% of trials were completed. Only 4 relevant publications were produced from all the trials in our study. Gemcitabine was the most common drug used. Use of gemcitabine alone or in combination with either capecitabine or cisplatin showed significant increase mean progression-free survival., Conclusion: This study revealed a low number of trials, lack of geographic diversity, and scarcity of publications concerning non-resectable GBC. Adequate management of is of great importance to reach effective therapies for this disease.

Background: Gastric cancer (GC) is the third most common cause of malignancy associated mortality globally. The cornerstone of curative treatment involves surgical gastrectomy. In this study, we explore clinical trials involving gastrectomy for GC, highlighting inadequacies and underlining promising surgical interventions and strategies., Materials and Methods: On 1 May 2020, ClinicalTrials.gov was explored for interventional trials related to gastrectomy for GC, without adding limitations for location or date. All data pertaining to the trials were collected. Characteristics such as phase, duration, enrolment size, location, treatment allocation, masking and primary endpoint were analysed., Results: One hundred thirty-eight clinical trials met the search criteria. Clinical trials were performed in only 14 countries; most of them occurring in China. Most trials (33%) were still in the recruiting phase. On average, the length of trials was 3.9 years. Most trials had parallel assignment, were randomised and masked. The primary endpoint which was mostly commonly studied was overall survival (33%). The most common intervention studied is laparoscopic gastrectomy in 43 (31%) trials., Conclusions: Our study exposed a small number of trials, publication rate, absence of geographic variety in clinical trials involving gastrectomy for GC. Adequate management of trial design can help decrease duration and increase validity of results. More trials comparing different surgical techniques are needed to update the surgical practice of gastrectomy for GC., Competing Interests: The authors declare no conflict of interest., (© the authors; licensee ecancermedicalscience.)

Background: Doping is a practice that is present in many sports and organizations, including mixed martial arts and the Ultimate Fighting Championship (UFC). The aim of this study is to explore the epidemiological patterns of doping among UFC athletes., Methods: We screened the official United-States-Anti-Doping-Agency® (USADA) website, the annual USADA reports and the official UFC website for information on fighters and anti-doping rule violations (ADRVs). Our dataset included gender, age, weight class, testing numbers, date of ADRV, type of ADRV, and duration of suspension. Appropriate statistical tests were conducted to assess for statistical significance., Results: USADA tested 1070 UFC athletes 2624 times as of late 2015 up till the end of 2019 (N = 1070). A total of 209 adverse findings were recorded; out of which, 102 ADRVs were committed by 93 athletes (8.7%) from all weight divisions. This constituted an adverse finding rate of 16.55 per 1000 test and an ADRV rate of 8.08 per1000 test. Mean age of sanctioned athletes was 32 years. Use of anabolic steroids was significantly the most common ADRV recorded (p = 0.018). The men's heavyweight division had an ADRV rate of 19.3 per 1000 tests, significantly higher than that of women's bantamweight division at 2 per 1000 tests (p = 0.03), women's featherweight division at 0 per 1000 tests (p = 0.009), and men's flyweight division at 3 per 1000 tests (p = 0.035). ADRV rate showed a significantly increasing trend among men's weight divisions (p < 0.001)., Conclusion: Doping is present in mixed martial arts. Increasing testing numbers, raising awareness and education on the risks of doping, and conducting further research on the issue is key to help resolve this problem., (© 2020 John Wiley & Sons, Ltd.)

Achilles tendinopathy is a prevalent overuse injury to the Achilles tendon causing prominent pain and reduction in quality of life. Several biomechanical and anatomical properties govern the pathology of the Achilles tendinopathy, and as a result, choosing the optimal treatment option is challenging. The aim of this review is to study the anatomical and biomechanical characteristics of this injury and explore the available treatment options in order to extrapolate the most suitable option with the best prognosis. Treatment modalities for Achilles tendinopathy vary and include non-operative and operative options. Non-operative treatment modalities include physical therapy, extracorporeal shockwave therapy, injectable agents, and bracing and taping. Operative treatment modalities include surgical procedures, both percutaneous and open. Treatment should be catered to the individual patient. Further research is required in order to confirm the efficacy of the available treatment options, test the viability of novel techniques and approaches, and discover possible new therapeutic modalities., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background and Objectives: Lebanon has witnessed an increase in the rates of several cancer sub-types over the past couple of years. The aim of our study is to investigate the incidence rates of colorectal cancer over 11 years in Lebanon and compare them with other countries., Materials and Methods: Data was collected from the National Cancer Registry (NCR) of Lebanon from the years of 2005 till 2015 inclusive. Data of other countries was retrieved from the online database "Cancer Incidence in Five Continents". The age-specific and age-standardized incidence rates (ASR(w)) were calculated and analyzed using Joinpoint regression., Results: Colorectal cancer ranked as the 5th most common cancer in Lebanon. The average ASR(w) was 12.6 per 100,00 for males and 10.7 per 100,00 for females. Colorectal cancer ASR (w) showed a significantly increasing trend in both males and females. Lebanon had the second highest incidence of colorectal cancer in the MENA region., Conclusion: Incidence of colorectal cancer has been increasing significantly over the course of our study. It is important to study the risk factors associated with colorectal cancer and develop proper preventive and screening policies in order to decrease exposure and therefore decrease incidence rates in the future.

Background and Objective: There is a pressing need for evidence-based interventions to address the devastating clinical and public health effects of the coronavirus disease 2019 (COVID-19) pandemic. The number of registered trials related to COVID-19 is increasing by the day. The objective of this study was to describe the characteristics of the currently registered interventional clinical trials related to COVID-19., Methods: We searched the World Health Organization's International Clinical Trials Registry Platform on May 15th, 2020. We included any entry that is related to COVID-19. We abstracted and then descriptively analyzed the following characteristics of the registered trials: study design, status, phase, primary endpoints, experimental interventions, and geographic location among other qualifiers., Results: We identified 1,308 eligible registered trials. Most trials were registered with ClinicalTrials.gov (n = 703; 53.7%) and the Chinese Clinical Trial Registry (n = 291; 22.2%). The number of participants to be enrolled across these trials was 734,657, with a median of 110 participants per trial. The most commonly studied intervention category was pharmacologic (n = 763; 58.3%), with antiparasitic medications being the most common subcategory. Although over half of the trials were already recruiting, we identified published peer-reviewed results for only 8 of those trials., Conclusion: There is a relatively large number of registered trials but with very few results published so far. Although our findings suggest an appropriate initial response by the research community, the real challenge will be to get these trials completed, published, and translated into practice and policy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background Weightlifting is a common type of sports training that develops the strength and size of skeletal muscles. Low back pain (LBP) is one of its most common complaints. This sport has become prevalent among adolescents and young adults as they work to enhance their physique and body image. The aim of our study is to explore the nature and cause of LBP in weightlifting adolescents and young adults in an aim of extrapolating proper preventive measures. Methods Participants were patients who engaged in weightlifting sports and had presented to our clinic with nonspecific LBP. They were examined and asked to rate and localize their pain. Back positioning during weightlifting techniques along with other exercise habits was explored. Patients with congenital or systemic diseases and fractures were excluded from our study. Results A total of 93 patients presented with LBP (age range: 16-26 years), all of whom partook in weightlifting (N=93). Localized pain was found in 43 patients (46%). Pain radiating to the left side was found in 31 patients (33%), while pain radiating to the right was found in 19 patients (21%). LBP localized at the level of L4-L5 was found in 44 cases (47%), while that localized at L5-S1 was found in 43 cases (46%). Only six cases localized pain at the level of L3-L4 (7%). A total of 23 cases required surgery (25%), while others were managed conservatively. All the participants (100%) reported their pain to be initiated during or after weightlifting maneuvers. Psychological symptoms were found in 13 cases (19%). Factors that helped relieve the pain included surgery, swimming, and wearing a back brace. Conclusion Weightlifting is a sport that utilizes heavy weights to engage the muscles in the body, and consequently, predisposes athletes to LBP. Using excessive weights and performing improper techniques puts the back in a compromising position that may lead to injury. Medical and sports personnel should raise awareness on the biomechanical properties of the lumbar spine and the correct spine-protective posture during training to help prevent these injuries in the future., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Fares et al.)

Background and Objectives  Cancer carries one of the heaviest burdens globally in terms of mortality. Lebanon is a middle-income Middle East country also plagued with cancer, as such a study and analysis of cancer trends and projections would serve a great benefit in the fight against the disease. Materials and Methods  All data pertaining to cancers in Lebanon were extracted from the National Cancer Registry of Lebanon Web site. Data were analyzed to produce trends over the years of our study (2008-2015). Ten-year projections were further calculated for the top cancers by the primary site using logarithmic models. Results  The top cancers in Lebanon are the breast, lung, colorectal, bladder, and prostate. The top cancers affecting females are the breast, lung, and colorectal. The top cancers affecting males are the prostate, lung, and bladder. Cancer cases are projected to increase in Lebanon over the next 10 years. Conclusion  Lebanon had a steady incidence rate of cancer cases during the time of our study. A more complete understanding of cancer trends and their ultimate reduction will require further research into the origins of specific cancers and the means of prevention and control., Competing Interests: Conflicts of Interest There are no conflicts of interest., (MedIntel Services Pvt Ltd. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background  Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) are two common malignancies worldwide and in Lebanon. Analysis of their trends plays a crucial role to better understand their origins and risk factors. This study will probe incidences of both types of lymphomas from 2005 to 2016, aiming to compare between the two malignancies according to age and sex and plot projections until 2026. Methods HL and NHL cases from 2005 to 2016 were collected from the National Cancer Registry of Lebanon. Data was stratified according to age and sex. Age-specific and age-standardized incidence rates were analysed using joinpoint regression; 10-year projections were predicted based on logarithmic models. Results Between 2005 and 2016, NHL was significantly more common than HL. NHL was higher in both genders. HL showed a bimodal age distribution while NHL peaked in elderly patients. NHL incidence rates in males increased significantly from 2005 to 2014 while HL incidence rates showed an insignificant rise. Over the next 10 years, NHL and HL cases are expected to increase in Lebanon. Conclusion HL and NHL are on the rise in Lebanon. Extensive research into the main factors contributing to these lymphomas is crucial in the fight against them. More efforts must be done by the government and health organizations to better control the disease., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Abdel Sater et al.)

Background: Central nervous system (CNS) cancers are rare but deadly, with little data in the literature to describe its incidence in Middle East and North Africa (MENA) region. This study investigates the incidence-rates of these cancers MENA, determine Lebanon's current state in contrast, compare the incidence-rates of these cancers in Lebanon to other countries from several regions of the world, and discuss contributing risk factors., Methods: CNS cancers data for the years 2005 to 2015 was collected from the National Cancer Registry of Lebanon and stratified by gender and age group. Age-specific and age-standardized incidence-rates were calculated and analyzed using Joinpoint regression. Age standardized incidence-rates to the world population [ASR(w)] for other countries were obtained from two online databases., Results: Lebanon ranked third and fourth in CNS cancers incidence in MENA region for males and females, respectively. However, Lebanon had low incidence when compared to other regions of the world. CNS cancers ASR(w) showed a non-significantly increasing trend over the period studied for Lebanese males and females. Incidence-rate increased with age in both sexes and the average age of incidence was around 44 years., Conclusions: Lebanon has relatively high incidence of CNS cancer in both sexes when compared to other MENA countries. CNS cancers incidence-rate is on the rise and children younger than 9 years as well as adults above 30 years are remarkably burdened by these diseases. Several risk factors, particularly ionizing radiation and pesticide exposure play a role in increased CNS cancers incidence among the Lebanese population.

Background: The novel coronavirus disease 2019 (COVID-19) has impacted many countries across all inhabited continents, and is now considered a global pandemic, due to its high rate of infectivity. Research related to this disease is pivotal for assessing pathogenic characteristics and formulating therapeutic strategies. The aim of this paper is to explore the activity and trends of COVID-19 research since its outbreak in December 2019., Methods: We explored the PubMed database and the World Health Organization (WHO) database for publications pertaining to COVID-19 since December 2019 up until March 18, 2020. Only relevant observational and interventional studies were included in our study. Data on COVID-19 incidence were extracted from the WHO situation reports. Research output was assessed with respect to gross domestic product (GDP) and population of each country., Results: Only 564 publications met our inclusion criteria. These articles came from 39 different countries, constituting 24% of all affected countries. China produced the greatest number of publications with 377 publications (67%). With respect to continental research activity, Asian countries had the highest research activity with 434 original publications (77%). In terms of publications per million persons (PPMPs), Singapore had the highest number of publications with 1.069 PPMPs. In terms of publications per billion-dollar GDP, Mauritius ranked first with 0.075., Conclusion: COVID-19 is a major disease that has impacted international public health on a global level. Observational studies and therapeutic trials pertaining to COVID-19 are essential for assessing pathogenic characteristics and developing novel treatment options., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Chahrour et al.)

Background The outbreak of the novel coronavirus disease in 2019 (COVID-19) caused a major public health crisis worldwide and challenged healthcare systems across the six continents. The high infectivity of the disease led many governments to adopt strict regulations and measures with the aim of containing its spread. The purpose of this study is to assess the incidence, severity, and territorial expansion of COVID-19. Methods Data from the World Health Organization was screened, and COVID-19 situation reports were extracted from January 21 up till March 14 (inclusive). Our data included the total number of cases, total number of new cases, total number of cured cases, and total number of related deaths. Percentage change of cases over the days of our study were calculated using the Joinpoint regression, with a significance level set at greater than 0.05. Results The total number of COVID-19 cases reached 156,622, with 5,845 subsequent deaths. China, Italy, and Iran have the highest number of cases worldwide. During the first 22 days, the incidence rate of COVID-19 increased significantly to reach 1.81 cases per million persons (p<0.001). That was followed by a significant decrease over the next 11 days (p<0.001) to reach 0.071 cases per million persons. A steady rise then followed, which saw a significant increase in incidence rate to 1.429 cases per million persons (p<0.001). Percentages of death and cured cases varied across the different countries; nevertheless, death percentages have generally been decreasing since the start of the crisis. Conclusion Adopting precautionary regulations such as social isolation, increasing sanitation, and employing strict quarantine measures have proved to be beneficial in containing the virus. Further research needs to be conducted to help discover therapeutic modalities and improve outcomes., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Khachfe et al.)

Metastasis is the hallmark of cancer that is responsible for the greatest number of cancer-related deaths. Yet, it remains poorly understood. The continuous evolution of cancer biology research and the emergence of new paradigms in the study of metastasis have revealed some of the molecular underpinnings of this dissemination process. The invading tumor cell, on its way to the target site, interacts with other proteins and cells. Recognition of these interactions improved the understanding of some of the biological principles of the metastatic cell that govern its mobility and plasticity. Communication with the tumor microenvironment allows invading cancer cells to overcome stromal challenges, settle, and colonize. These characteristics of cancer cells are driven by genetic and epigenetic modifications within the tumor cell itself and its microenvironment. Establishing the biological mechanisms of the metastatic process is crucial in finding open therapeutic windows for successful interventions. In this review, the authors explore the recent advancements in the field of metastasis and highlight the latest insights that contribute to shaping this hallmark of cancer.

Objectives: To explore the patterns and trends of upper limb injuries in Major League Baseball (MLB)., Design: Descriptive Epidemiological Study., Setting: The MLB website was screened for injuries between 2010 and 2016, inclusive., Participants: Players that were placed on the Injured Lists (IL) due to upper limb injuries., Main Outcome Measures: The players' position, injury location, injury information, date of injury, and time spent on the IL were collected., Results: A total of 3512 injuries were documented; 1609 injuries (49%) affected the upper limb (n = 1609). On average, players were placed on the IL for 71 days (std dev = 57 days) due to these injuries. The shoulder was the anatomic location most prone to injury (35%). The elbow had the highest average days on IL (94 days; std dev = 63 days), significantly higher than all other anatomic locations (P < 0.001). Strain was the most cited cause for upper limb injuries. Pitchers had a significantly higher mean incidence rate (MIR) than fielders and catchers for shoulder, elbow, arm, and forearm injuries. Pitchers had significantly lower wrist and hand injury MIRs when compared to fielders and catchers. April had the highest burden of injuries with 380 injuries (24%) recorded. Surgery was performed on 225 injuries (14%)., Conclusion: Upper limb injuries are prevalent in the MLB, especially among pitchers. The shoulder is the anatomic location most prone to injury. Better understanding of the trends and patterns of these injuries will help in establishing better prevention policies., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Heparin and heparin-like molecules have shown some promise in the treatment of several cancers. These molecules have roles in angiogenesis, cell proliferation, immune system modulation, cell migration, and cellular invasion. The pathways and mechanisms used by these molecules to inhibit the proliferation of cancer cells aid in understanding the utilization of these molecules in potential treatments. Our aim is to review the use of heparin and heparin-like molecules in cancer treatment, explore the results, and discuss their potential downfalls., Methods: Publications on heparin and heparin-like molecules and compounds were collected from the PubMed and EMBASE databases. Boolean operators and MeSH terms related to heparin, heparin-like molecules, and cancer were used to conduct this search. The articles were reviewed by the authors., Results: Several heparin mimetics are showing promise in cancer treatment. Various studies using mimetics alone or in combination with chemotherapy have been conducted and have yielded mixed results. They work on multiple target molecules, mostly receptors such as fibroblast growth factor and endothelial growth factor. The main types of cancers targeted by these drugs are multiple myeloma, pancreatic cancer, hepatocellular carcinoma (HCC), and other solid tumors., Conclusion: Although limited clinical evidence of efficacy and potential pitfalls are present, heparin and heparin-like molecules have shown potential in the management of cancer patients. Additional research is required to fully understand the biological mechanisms utilized by these molecules in cancer treatment., 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 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Since the Syrian conflict started, Lebanon became a common destination receiving a huge number of Syrian refugees that are living in camps spread all over the country, with the largest concentration in the Bekaa Valley. Generous steps are being taken to increase the access to formal education, such as offering free public education and opening second shifts in the public schools in the afternoon. Yet barriers, such as child labor and health-related factors like the spreading of some communicable diseases, like Leishmania , are keeping children out of classroom. The present study was done with the aim of investigating the effect of leishmaniasis on the performance and the academic achievement of Syrian refugee children. The results showed varying degrees of knowledge and dealing with the case of leishmaniasis. The disease clearly had an effect on the students' attendance in schools, and by proxy on their academic performance., Competing Interests: The authors declare they have no conflicts of interest., (© 2019 Atlantis Press International B.V.)

Aim: In this work, we aim to assess the maternal health in terms of maternal mortality ratios and lifetime risk of maternal death in of women in the Arab World., Methods: Data on maternal mortality rates (MMR) and lifetime risk of maternal death (LTR) were extracted from the official databases of the United Nations Children's Fund. Annual Percentage Change was calculated using Joinpoint regression model. Statistical significance among countries was determined using one-way analysis of variance (anova) on spss version 25.0 (IBM SPSS, 2017)., Results: The MMR and LTR significantly decreased in almost all Arab countries. Somalia was found to be the country with the highest burden of MMR, while Gulf countries had the lowest burden., Conclusion: Our study shows a decrease in the MMR and LTR of maternal death in the Arab world. Although there is a decrease in these rates, but continuous research and efforts must be undergone to better develop the health care system in a great number of Arab countries to decrease the burden of maternal deaths., (© 2019 Japan Society of Obstetrics and Gynecology.)

Objectives: To explore the epidemiological patterns and musculoskeletal characteristics of lower limb injuries in Major League Baseball (MLB)., Design: Descriptive epidemiological study., Setting: The MLB was screened for injuries between 2010 and 2016, inclusive., Participants: Players that were placed on the Disabled List (DL) and had lower limb injuries., Main Outcome Measures: Our database entailed the player's position, injury location, injury cause, and time spent on the DL. Analysis of characteristics and mean incidence rates (MIR) were conducted, and P values<0.05 were considered significant (CI 95%)., Results: A total of 3546 injuries were recorded; 1053 injuries (29.7%) affected the lower limbs (n = 1053). On average, 150.4 players per season were placed on the DL for a mean of 45.7 days. Thighs were the most common site of injury, whereas hip injuries had the highest average days on DL (62 days). Fielders had a significantly higher MIR of lower leg injuries when compared to pitchers (P = 0.007) and catchers (P = 0.024), and a significantly higher MIR of foot injuries than that of pitchers (P = 0.035). April was the month with the highest number of injuries (224 injuries, 21.3%). Only 43(4%) injuries required surgical intervention., Conclusion: Lower limb injuries are increasing in the MLB. Understanding the neuromuscular patterns of injuries will help in extrapolating better prevention policies., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Hypertrophic cardiomyopathy (HCM) is a genetic disorder with a very large global burden for which more therapeutic management regimens are required., Objectives: In this study, the authors explore HCM-related clinical trials, determine the shortcomings leading to the lack of development of new HCM therapies, and attempt to shed light on potential areas for improvement., Methods: In January 2019, the authors completed a search on ClinicalTrials.gov for all therapeutic and interventional clinical trials involving HCM, without any limits for location or date. Information on trial characteristics such as phase, start and end dates, sample size, experimental intervention, publications, study design, selection criteria, and results were collected and analyzed., Results: Sixty-three trials met the selection criteria. The average trial duration across phases was around 3 years. Around one-half of the trials were conducted in North America (United States and Canada) and 44% of the trials were in their early phases (I and II). Approximately one-third of the trials were completed. Only 14 publications were produced from all the clinical trials studied., Conclusions: The study revealed a low number of trials, lack of geographic diversity, and scarcity of published results concerning HCM clinical trials. Proper management of HCM trials is of vast importance to achieve effective therapies., (Copyright © 2019 World Heart Federation (Geneva). Published by Elsevier B.V. All rights reserved.)

Background and Objectives : Breast cancer is the most prevalent cancer in women worldwide. Lebanon is a developing country in the Middle East with a prominent breast cancer incidence. The aim of our study was to explore the incidence rates of breast cancer in Lebanon from 2005 to 2015, and compare them to the rates of other countries. Materials and Methods : Breast cancer data for the years 2005-2015 was collected from the National Cancer Registry of Lebanon and stratified by gender and age group. Age-specific and age-standardized incidence rates were calculated and analyzed using joinpoint regression. Age-standardized incidence rates in the world population (ASR(w)) were obtained for other countries, from two online databases. Results : Breast cancer was found to be the most prevalent cancer in Lebanon, accounting for 20% of all cancer cases. The average ASR(w) was 96.5 per 100,000. Over the studied period, breast cancer ASR(w) in Lebanon showed a significantly increasing trend with an annual percent change (APC) of +4.6. Moreover, the APC of breast cancer age-specific rates significantly increased for the age groups 45-49 ( p = 0.013), 50-54 ( p < 0.001), 55-59 ( p = 0.001), 60-64 ( p = 0.002), 65-69 ( p = 0.003), 70-74 ( p < 0.001), and 75+ years ( p < 0.001). Lebanon had the highest breast cancer ASR(w), when compared to other regional countries, and trailed only behind Denmark, when compared to selected countries from different parts of the world. Conclusions : Breast cancer incidence in Lebanon is among the highest in the world. Future studies should focus on exploring the genetic profile of the Lebanese population in an aim to extrapolate proper prevention guidelines.

Background and Objectives : Lung cancer (LC) is the most common cancer in the world. Developing countries in the Middle East and North Africa (MENA) region, including Lebanon, have witnessed a great increase in the incidence rates of this disease. The aim of our study is to investigate the incidence rates of lung cancer in Lebanon from 2005 to 2015 and to compare these rates to other countries from the MENA region and other regions of the world. Material and Methods : Lung cancer data for the years 2005-2015 were collected from the National Cancer Registry of Lebanon and stratified by gender and age group. Age-specific and age-standardized incidence rates were calculated and analyzed using joinpoint regression. Age-standardized incidence rates to the world population (ASR(w)) for other countries were obtained from two online databases. Results : Lung cancer ranked as the second most common cancer in Lebanon and accounted for 9.2% of all newly diagnosed cancers. Lung cancer ASR(w) showed a significantly increasing trend over the period studied for males and females. Lung cancer ASR(w) among males in Lebanon came second after Malta when compared to other MENA countries, but it was among the lowest when compared to non-MENA countries. For females, Lebanon ranked first when compared to other MENA countries but was among the lowest when compared to countries in other regions of the world. The lung cancer incidence rate increased with age in both sexes and 89.2% of patients were 50 years of age or older. Conclusion : Lebanon has the highest incidence of LC in females and the second highest for males in the MENA region. The lung cancer incidence rate is on the rise and older age groups are much more burdened by this disease than the young ones. Several risk factors, particularly smoking, play a role in increased LC incidence among the Lebanese population., Competing Interests: The authors declare no conflict of interest.