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Aims: Conflicting data exists about long-term outcomes in young women and men experiencing acute myocardial infarction (AMI)., Methods: The FAST-MI program consists of three nationwide French surveys carried out 5years apart from 2005 to 2015, including consecutive patients with AMI over a 1-month period with up to 10-year follow-up. The present analysis focused on adults≤50 yo according to their gender., Results: Women accounted for 17.5% (335) of the 1912 patients under 50 yo and had a similar age as men (43.9±5.1 vs. 43.9±5.5years, P=0.92). They received less percutaneous coronary interventions (PCI) than men (85.9% vs. 91.3%, P=0.005), even in ST-elevation myocardial infarction (83.6% vs. 93.5%, P<0.001). Recommended secondary prevention medications were less frequently prescribed at discharge in women (40.6% vs. 52.8%, P<0.001), a trend that persisted in 2015 (59.1% vs. 72.8% in 2015, P<0.001). Still, ten-year survival was similar in men (90.5%) and women (92.3%) (crude HR: 0.86 [95% CI: 0.55-1.35], P=0.52, adjusted HR: 0.63 [95% CI: 0.38-1.07], P=0.09); similar results were found for ten-year survival among hospital survivors (91.2% in men vs. 93.7% in women, adjusted HR: 0.87 [95% CI: 0.45-1.66], P=0.66). Of the 1684 patients alive at hospital discharge with morbidity follow-up≥6months available, death, AMI or stroke at 8years occurred in 12.9% men and 11.2% in women (adjusted HR: 0.90 [95% CI: 0.60-1.33], P=0.59)., Conclusions: Young women with AMI undergo less cardiac interventions and are less often prescribed secondary prevention treatment than men, even when significant coronary artery disease is present, but keep a similar long-term prognosis after AMI. Optimal management of these young patients, regardless of gender, is necessary to ensure best outcomes after this major cardiovascular event., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Background Quality of Life (QoL) is a prognostic factor in heart failure (HF) of patients with acquired cardiac disease. The aim of this study was to determine the predictive value of QoL on outcomes in adults with congenital heart disease (ACHD) and HF. Methods and Results Quality of life of 196 adults with congenital heart disease with clinical heart failure (HF) (mean age: 44.3±13.8 years; 51% male; 56% with complex congenital heart disease; 47% New York Heart Association class III/IV) included in the prospective multicentric registry FRESH-ACHD (French Survey on Heart Failure-Adult with Congenital Heart Disease) was assessed using the 36-Item Short Form Survey (SF-36), a patient-reported survey. The primary end point was defined by all-cause death, HF-related hospitalization, heart transplantation, and mechanical circulatory support. At 12 months, 28 (14%) patients reached the combined end point. Patients with low quality of life experienced major adverse events more frequently (logrank P =0.013). On univariate analysis, lower score at physical functioning (hazard ratio [HR], 0.98 [95% CI, 0.97-0.99]; P =0.008), role limitations related to physical health (HR, 0.98 [95% CI, 0.97-0.99]; P =0.008), and general health dimensions of the SF-36 (HR, 0.97 [95% CI, 0.95-0.99]; P =0.002) were significantly predictive of cardiovascular events. However, after multivariable analysis, SF-36 dimensions were no longer significantly associated with the primary end point. Conclusions Patients with congenital heart disease with HF and poor quality of life experience severe events more frequently, making quality of life assessment and rehabilitation programs essential to alter their trajectory.

Background: According to the guidelines, surgical aortic valve replacement (SAVR) is recommended in patients at low surgical risk (EuroSCORE II<4%), whereas for other patients, the decision between transcatheter aortic valve implantation (TAVI) and surgery should be made by the Heart Team, with TAVI being favoured in elderly patients., Aim: The RAC prospective multicentre survey assessed the respective contributions of age and surgical risk scores in therapeutic decision making in elderly patients with severe symptomatic aortic stenosis., Methods: In September and October 2016, 1049 consecutive patients aged ≥ 75 years were included in 32 centres with on-site TAVI and surgical facilities. The primary endpoint was the decision between medical management, TAVI or SAVR., Results: Mean age was 84±5 years and 53% of patients were female. The surgical risk was classified as high (EuroSCORE II>8%) in 18% of patients, intermediate (EuroSCORE II 4-8%) in 34% and low (EuroSCORE II≤4%) in 48%. TAVI was preferred in 71% of patients, SAVR in 19% and medical treatment in 10%. The choice of TAVI over SAVR was associated with older age (P<0.0001) and a higher EuroSCORE II (P=0.008). However, the weight of EuroSCORE II in therapeutic decision making markedly decreased after the age of 80 years. Indeed, 77% of patients aged ≥ 80 years were referred for TAVI, despite a low estimated surgical risk., Conclusions: The impact of risk scores depends strongly on age, and decreases considerably after 80 years, most patients being referred for TAVI, independent of their estimated surgical risk. Despite medical advancements, 10% of patients were still denied any intervention., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Backgrounds: Optimal pain management in bariatric patients is crucial for early recovery. This study aims to evaluate the effects of magnesium and ketamine combination on morphine consumption after open bariatric surgery (primary outcome), as well as on postoperative pain scores and occurrence of side effects., Method: A total of 60 patients undergoing elective open gastric bypass were randomized into 3 groups. All patients received the same general anaesthesia protocol. The magnesium and ketamine group (Mg + K) received an IV bolus of magnesium 50 mg/kg and ketamine 0.2 mg/kg followed by continuous infusion of magnesium (8 mg/kg/h) and ketamine (0.15 mg/kg/h) until extubation. The ketamine group (K) received the same bolus and infusion of ketamine, together with a bolus and continuous infusion of normal saline. The placebo group (P) received normal saline. All patients received 48 h of paracetamol 1 g IV q6h and morphine sulphate 0.1 mg/kg subcutaneous q6h PRN. Morphine consumption, VAS pain scores and occurrence of side effects were recorded for 48 h postoperatively., Results: Patients in group (Mg + K) (2.4 ± 2.62 mg) and in group (K) (2.8 ± 2.66 mg) had significantly lower morphine consumption in the PACU compared with the patients in group (P) (4.85 ± 4.51 mg) (p = 0.045). Patients in group (Mg + K) consumed significantly less morphine the first 24 postoperative hours, with a relative reduction of 87% and 21% compared with group (K) and group (P) respectively (p = 0.028). However, this difference was not observed at 48 h. No significant difference was shown between the three groups in terms of nausea and vomiting, time to extubation or excessive sedation., Conclusion: The association of magnesium and ketamine bolus followed by infusion in open bariatric surgery appears to be safe and decreases morphine requirements in the first 24 h compared with both ketamine alone and placebo.

Background: Non-steroidal anti-inflammatory drugs (NSAIDs) are cornerstone in multimodal analgesia protocols. This point is of great value in morbidly obese patients due to the high prevalence of restrictive pulmonary disease and obstructive sleep apnea. The aim of this study was to test the hypothesis that NSAIDs do not increase acute bariatric surgery complications while optimizing postoperative analgesia., Methods: Databases of two medical centers were retrospectively reviewed to find all patients who underwent bariatric surgery between 1 January 2017 and 31 December 2017. Inclusion criteria were BMI greater than 30 kg/m 2 and age of 16-75 years old. Patients who suffered from severe organ failure or coagulation disorders were excluded. Patient's demographics, obesity-related diseases (diabetes, hypertension, dyslipidemia), postoperative pain scores, and morphine consumption in PACU, as well as early and late surgical complications, were collected. Patients included from the first institution (where NSAIDs analgesia was prohibited: control group) were compared to patients from the second institution (where NSAIDs analgesia was mandatory: case group)., Results: The study population included 270 patients, 134 in the control group, and 136 in the case group. NSAIDs usage produced better analgesia with significant reduction in morphine consumption and PACU length of stay. Also, incidence of surgical complications was the same in the two groups., Conclusions: NSAIDs administration do not increase postoperative complication rate after bariatric surgery. Although NSAID administration provided better analgesia and shorter PACU stay, future prospective studies are needed to confirm these encouraging results and to evaluate their impact on postoperative rehabilitation.

Competing Interests: There are no conflicts of interest.

Background: The FAST-MI programme, consisting of 1-month surveys of patients admitted to hospital for acute myocardial infarction (AMI) in France, has run since 2005., Aim: To gather data on the characteristics, management and outcomes of patients hospitalized for AMI at the end of 2015 in France and to provide comparisons with the previous surveys., Methods: Consecutive adults with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment-elevation myocardial infarction (NSTEMI) with symptom onset≤48hours were included over a 1-month period, with a possible extension of recruitment for 1 additional month. Patients with AMI following cardiovascular procedures were excluded. In all, 204 centres participated in the survey (114 community hospitals, 40 academic, 48 private clinics, 2 army hospitals), representing 78% of French centres managing AMI patients. Inclusion started from 5 October 2015. Data were collected on-site from source files by external research technicians, using an electronic case record form with automatic quality checks. Centralized biology was organized in voluntary centres to collect RNA and DNA samples, serum and stools. Long-term follow-up was organized centrally with interrogation of municipal registry offices, physicians and by direct contact with the patients or their families., Results: A total of 5291 patients were included over the entire recruitment period, with 3813 included during the first month (STEMI: 49%, NSTEMI: 51%). Mean age was 66±14 years, 29% were≥75 years of age, 28% were women; 80% presented with typical chest pain. In STEMI patients, 6% received intravenous fibrinolysis and 71% underwent primary PCI. The hospital death rate was 2.7% (STEMI: 2.8%, NSTEMI: 2.5%)., Conclusions: Recruitment was in line with expectations and the first data show that management has continued to evolve since the 2010 survey, with continued improvement in hospital outcomes., (Copyright © 2017. Published by Elsevier Masson SAS.)

Objectives: Use of chronic opioid therapy has increased substantially over the past few years, even though opioid therapy is associated with potentially serious harms, including opioid-related adverse effects and outcomes. Prescription of opioids for chronic pain, particularly nonmalignant chronic pain, remains controversial. In the midst of this controversy, patterns of actual prescription and influences on these patterns are not well understood. This study aims to describe the frequency of prescription of opioid analgesics in a university hospital, the attitudes of doctors towards this category of drugs, and the follow-up modalities of patients taking these drugs. The study also explores the association between the practitioners' characteristics and the modalities of prescription., Design and Methods: A survey was delivered to 112 doctors and surgeons in the hospital during the four months between August and December 2013 and it was returned by 55 (49.0%). The survey consists of three parts. The first part addresses the frequency and reluctance of doctors' prescription of opioids and other analgesics for acute and chronic pain. The second part studies the doctors' attitudes and concerns towards opioids. It explores the belief of the doctors in the efficacy of this category of drugs, their confidence in prescribing such medications and the eventual side effects they might worry about. The third part of the survey studies the modalities of evaluation prior to the prescription and the modalities of follow-up of the patients receiving a long-term opioid treatment., Results: Overall, 76.4% of doctors reported they sometimes, frequently, or always, prescribe opioids, which, using the Wilcoxon test, proved to be a significantly lower frequency than for prescribing of minor analgesics or nonsteroidal anti-inflammatory drugs (NSAIDS). Similarly, 60.1% reported a reluctance to prescribe opioids for chronic nonmalignant pain, which was a significantly greater reluctance than for cancer pain. The age and sex of the participants were unrelated to prescribing, but those with specialty training and use of practice guidelines were more likely to prescribe opioids and were less reluctant to do so. A majority of practitioners felt that opioids are effective for the treatment of chronic nonmalignant pain and that they have the sufficient training to prescribe them adequately; however, they still worry about the long-term prescription of opioids, particularly fearing the psychological dependence this treatment might cause. Using a series of Spearman correlation tests, we found that practitioners who thought they were adequately trained and who believed in the efficacy of long-term opioid treatment were more likely to prescribe them but that the worries about side effects decreased the frequency of prescription. A significant proportion of practitioners do not evaluate addiction risk factors of patients before prescribing opioids. The results concerning the modalities of follow-up of prescription were very heterogeneous with 87% of practitioners not explaining and 65% not screening for adverse effects. We similarly found that the frequency of follow-up and the management of patients who were exhibiting signs of dependence were very diverse., Conclusion: The results of this study were compatible with those of other recent studies about opioid prescription. The doctors practicing in the university hospital Hôtel-Dieu de France de Beyrouth present comparable prescription patterns, independent of their personal or professional characteristics, and they are more confident in their prescription when professionally trained for it. However, they exhibit a notable heterogeneity in their attitudes towards opioids and in their modalities of evaluating patients receiving long-term treatment. These results suggest a need for additional training in the management of this category of drugs., (Copyright © 2016. Published by Elsevier Masson SAS.)

Individualization of acute postoperative pain treatment on an evidence-based decision process is a major health concern. The aim of this study is to investigate the influence of genetic and non-genetic factors on the variability of response to morphine in acute postoperative pain. A group of nighty-five patients undergoing major surgery were included prospectively. At 24 h, a logistic regression model was carried out to determine the factors associated with morphine doses given by a Patient Controlled Analgesia device. The dose of morphine was associated with age (p = 0.011), patient weight (p = 0.025) and the duration of operation (p = 0.030). This dose decreased with patient's age and duration of operation and increased with patient's weight. OPRM1 and ABCB1 polymorphisms were significantly associated with administered dose of morphine (p = 0.038 and 0.012 respectively). Patients with at least one G allele for c.118A>G OPRM1 polymorphism (AG/GG) needed 4 times the dose of morphine of AA patients. Additionally, patients with ABCB1 CT and CC genotypes for c.3435C>T polymorphism were 5.6 to 7.1 times more prone to receive higher dose of morphine than TT patients. Our preliminary results support the evidence that OPRM1/ABCB1 genotypes along with age, weight and duration of operation have an impact on morphine consumption for acute postoperative pain treatment.

Opioids remain essential drugs for the treatment of severe cancerous pain. However, many countries have developed new regulations and policies for a better availability and accessibility of these drugs. Lebanon is not too far from these advanced strategies. The Ministry of Health and specifically the Narcotic Department have adjusted regulations related to opioid prescriptions and have registered many new opioid drugs in 2012 for a better pain-free life for our patients. However, there is still a lot to do in this field.

The history of pain is one of the concepts that have divided Cartesian thinkers and mystical philosophers in the Western civilization over centuries. Depending on the historical period, different dogmas and morals intersect, oppose or attempt conciliation. The attitude towards pain evolved with the evolution of mentalities in the broad sense but also by relying on scientific discoveries in the field. Yesterday, pain was accepted or sublimated. Today, taking care of pain is a patient basic right and an obligation for the practitioner.

In this case series, we present the effectiveness of multilevel nerve stimulator-guided paravertebral block (PVB) technique in obese women of body mass index ≥30 kg/m(2) undergoing breast cancer surgery with or without axillary dissection. Twenty-six obese women were included in this case series. Block classification, hemodynamics and complication rate, postoperative nausea and vomiting, postoperative analgesic consumption, post-anesthesia care unit (PACU) stay, and hospital stay were recorded. All patients were hemodynamically stable during the operation, and no complications were noted. Patients stayed 69 min on average in the PACU and were discharged within 2 days. Confirmation of the landmark was established from the initial attempt in 61.5%. Surgical PVB was achieved in 76.9% of the patients; the failure rate of the technique was 11.5%. This case series suggested that the multilevel nerve stimulator-guided PVB may be an effective technique for obese patients undergoing breast cancer surgery, although further studies are needed to compare PVB and general anesthesia.

Introduction: Varicocelectomy is a common operation in urology associated with considerable postoperative pain. The aim of this prospective, randomized, double-blind study was to investigate whether a combination of general anesthesia and bilateral nerve stimulator guided paravertebral nerve blocks could provide better postoperative pain relief compared to general anesthesia in combination with placebo paravertebral nerve block., Methods: Sixty patients scheduled for varicocelectomy were randomized prospectively. Thirty patients each in either the active group (general anaesthesia combined with nerve stimulator guided bilateral paravertebral block) or the control group (general anaesthesia combined with normal saline nerve stimulator guided bilateral paravertebral block). Postoperative pain was assessed by visual analogue scale scores at predetermined time intervals., Results: The active group was found to have better postoperative pain-relief (p < 0.005), reduced need for analgesics (p < 0.05), and also a more rapid return to normal activities (p < 0.001) compared to control group. Higher surgeon and patient satisfaction (p < 0.001) were noted in the active group compared to the control group., Conclusion: Preoperative paravertebral blockade combined with general anesthesia showed significantly reduced postoperative pain scores and analgesic consumption, earlier return to normal activity and was associated with better patient and surgeon satisfaction during varicocelectomy surgery.

Introduction: Postoperative pain relief in Lebanon is a public health problem because its coverage is insufficient., Study Design: A survey was performed with a questionnaire distributed to anaesthesiologists during the Lebanese national meeting of anaesthesia in May 2006., Results: A total of 106 out of the 230 distributed questionnaires were collected. The coverage of the postoperative pain is different in the university hospitals and others. A preoperative information and postoperative evaluation of pain are only performed by 26% of anesthesiologists. A multimodal analgesia is begun in the operative room or in postanaesthesist care unit for 92% of the patients. Only 71% of the anaesthesiologists have pumps for patient-controlled analgesia. Written protocols for postoperative analgesia are available in only 58% of the centres. Among anaesthesiologists, only 36% have an initial and/or continuous formation to treat the postoperative pain. The major obstacle for improvement of postoperative pain is the cost of such treatments, which must be supported by the patients., Conclusion: Even if there is a good awareness of the importance to relieve the postoperative pain, important efforts must be done in this domain in Lebanon.

Breast cancer surgery is frequently associated with postoperative nausea, vomiting, pain and painful restricted movement. It is well established that thoracic paravertebral block with or without general anesthesia provides better postoperative analgesia and reduces the risk of nausea and vomiting after breast surgery as well as the incidence of chronic pain. Paravertebral block improves the quality of recovery after breast cancer surgery and provides the patient with the option of ambulatory discharge.

Opioid analgesics are essential for the management of moderate to severe pain. In spite of their documented effectiveness, opioids are often underutilized, a factor which has contributed significantly to the undertreatment of pain. Many countries have developed true national policies on cancer pain and palliative care, and in others only guidelines for care have been developed. Ideally, national policies facilitate and legislate not only a patient's right to care, but also the necessary components of education and drug availability which are so critical for the appropriate achievement of public health programs.

Effective delivery of high-quality palliative care requires effective interprofessional team working by skilled healthcare professionals. Palliative care is therefore highly suitable for sowing the seeds of interprofessional team working in early professional undergraduate medical education. Integrating palliative medicine in undergraduate medical education curricula seems to be a must. In this review, we present as an example the Palliative and End-of-Life Care Curriculum (PEOLC) used in Canada for undergraduate medical education and underline the need for such a national curriculum in Lebanon. One must keep in mind that medical education does not stop at the end of the medical school, ongoing learning needs exist. Continuous medical education in palliative care should also be emphasized; the overall goal is promoting palliative medicine. Respecting and protecting human dignity is the right of every patient.

The intention of this prospective study was to evaluate the role of the musculocutaneous and radial nerves in elbow flexion and forearm supination. The study included 29 patients having loco-regional anaesthesia for minor hand surgery. Elbow flexion and forearm supination forces were evaluated before and after an isolated musculocutaneous nerve block in one group and an isolated radial nerve block in another group. The results showed that the biceps tendon is responsible for 47% of the forearm supination force and the combination of brachioradialis and the supinator for 64% of this force. It showed also that the musculocutaneous and radial nerves contribute by 42% and 27.5%, respectively, to the flexion force of the elbow. These results are intended to help surgeons in decision making when treating chronic biceps tendon rupture, in repair of traumatic brachial plexus neuropathy and in using tendon transfers, such as the Steindler transfer, around the elbow.

Goal of the Study: Lumbar microdiscectomy surgery is already performed under spinal anesthesia (SA) in many institutions. The aim of this study is to compare the quality of analgesia and recovery after SA when compared to general anesthesia (GA) after lumbar microdiscectomy surgery., Methods: Following light sedation, SA is performed with the patient in the left lateral decubitus position, one to two levels above the herniated disc level. Isobaric 0.5% bupivacaine 3-3.5 ml was injected intrathecally followed by wound infiltration with 15 ml of bupivacaine with 1/200 000 epinephrine prior to surgical incision., Results: Despite randomization, we found significantly more females in the GA group. Pain scores at 4 and 8 h postoperatively were lower in SA group as well as total analgesic consumption during the first 24 h. Postoperative recovery including time to drinking, eating and walking were more rapid after SA when compared to GA. During the postoperative period, the incidence of urinary retention was comparable between groups but the occurrence of postoperative nausea and vomiting was significantly higher in the GA group. Moreover, the overall patient's and surgeon's satisfaction were significantly better in the SA group., Conclusion: SA associated to wound infiltration using bupivacaine is an interesting alternative to general anesthesia for outpatient lumbar microdiscectomy surgery.

During a routine ultrasound study on a fetus at 21 weeks, nuchal edema was noted. At 21 weeks, repeat ultrasound study at our unit showed scalp and neck edema and a femur length/biparietal diameter ratio below the mean. Transabdominal chorionic villus sampling identified a 48.XYY, +21 chromosome constitution. The fetus had normal internal/external genitalia and signs of Down syndrome.