From the Editor
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Ahmad Husari
Editor, Middle-East Journal of Internal Medicine
Director, American University of Beirut Sleep Disorders Center
Director, American University of Beirut outpatient clinical care services
Assistant Professor
Division of Pulmonary and Critical Care Medicine
American University of Beirut Medical Center
Beirut Lebanon
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This is the first issue this year of the journal that has a number of interesting papers dealing with various subjects of interest. There are three papers that dealt with Sickle Cell Disease.

Mustafa et al., looked at improving the outcome of Sickle Cell disease patients in a resource limited setting Sudan Sickle Cell Anemia Center (SSCAC). They stressed that it is a promising and developing experience. In 2010, the percentage of newborns with SCD in sub-Saharan Africa was 79%, and this proportion is expected to increase to 88% by 2050. Africa has high mortality rates ranging from 50 to 90% for those aged less than 5 years. This high mortality is due to the lack of several facilities like prenatal diagnostic services, systematic follow-up, and life-saving measures such as penicillin prophylaxis, vaccination for common bacterial diseases, and the provision of disease-modifying treatment with Hydroxyurea, and Poor access to hematopoietic stem cell transplantation. Infectious diseases like malaria may also play a role in increasing the severity and mortality. The prevalence rate of sickle cell anemia in Sudan ranging from 2 to 30.4%. The highest prevalence of SCA in the Sudanese population is found in Western Sudan residents. Because of this increased prevalence of SCD in west Sudan, it is of high importance to improve the quality of care for sickle cell disease patients in this area. The authors present their experience at SSCAC.

Helvaci*, et al., tried to understand the underlying mechanism of pulmonary hypertension (PHT) in the sickle cell diseases (SCD). All patients with the SCD were included. The study included 434 patients (212 females) with similar mean ages in males and females (30.8 versus 30.3 years, respectively, p>0.05). Smoking (23.8% versus 6.1%, p<0.001) and alcohol (4.9% versus 0.4%, p<0.001) were higher in males, significantly. Transfused units of red blood cells (RBC) in their lives (48.1 versus 28.5, p=0.000), disseminated teeth losses (<20 teeth present) (5.4% versus 1.4%, p<0.001), chronic obstructive pulmonary disease (COPD) (25.2% versus 7.0%, p<0.001), ileus (7.2% versus 1.4%, p<0.001), cirrhosis (8.1% versus 1.8%, p<0.001), leg ulcers (19.8% versus 7.0%, p<0.001), digital clubbing (14.8% versus 6.6%, p<0.001), coronary heart disease (CHD) (18.0% versus 13.2%, p<0.05), chronic renal disease (CRD) (9.9% versus 6.1%, p<0.05), and stroke (12.1% versus 7.5%, p<0.05) were all higher but not PHT (12.6% versus 11.7%, p>0.05) in males, significantly. The authors concluded that SCD are severe inflammatory processes on vascular endothelium, particularly at the capillary level since the capillary system is the main distributor of hardened RBC into the tissues. Although the higher smoking, alcohol, and disseminated teeth losses, COPD, ileus, cirrhosis, leg ulcers, digital clubbing, CHD, CRD, and stroke-like atherosclerotic consequences in male sex, PHT was not higher in them in the present study. In another definition, PHT may not have an atherosclerotic background in the SCD. Instead, the hardened RBC-induced capillary endothelial damage, inflammation, edema, and fibrosis around the alveoli may be the major underlying cause.

Helvaci*, et al., tried to understand prevalence of chronic obstructive pulmonary disease (COPD) in both genders in sickle cell diseases (SCD).All cases with the SCD in the absence of smoking and alcohol were included. The study included 368 patients (168 males). Mean ages were similar in males and females (29.4 versus 30.2 years, respectively, p>0.05). Mean values of body mass index (BMI) were similar in males and females, too (21.7 versus 21.6 kg/m2, respectively, p>0.05). Interestingly, total bilirubin value of the plasma (5.2 versus 4.0 mg/dL, p=0.011), transfused units of red blood cells (RBC) in their lives (46.8 versus 29.2, p=0.002), COPD (20.8% versus 6.0%, p<0.001), and digital clubbing (13.0% versus 5.5%, p<0.001) were all higher in males. Whereas painful crises per year (5.0 versus 5.0), pulmonary hypertension (10.1% versus 12.5%), acute chest syndrome (2.3% versus 3.5%), mortality (8.3% versus 6.5%), and mean age of mortality (29.0 versus 32.5 years) were similar in males and females, respectively (p>0.05 for all). The authors concluded that SCD are severe inflammatory processes on vascular endothelium particularly at the capillary level, since capillary system is the main distributor of hardened RBC into tissues. The capillary endothelial damage, inflammation, edema, and fibrosis induced hypoxia may be the underlying cause of COPD in the SCD. Although the similar BMI and absence of smoking and alcohol, the much higher prevalence of COPD may be explained by the dominant role of male sex in life according to the physical power that may accelerate systemic atherosclerotic process in whole body.

Abyad & Hammami in the first of a series on Frailty discusses frailty. They stressed Life expectancy continues to rise globally. However, the additional years of life do not always correspond to years of healthy life, which may result in an increase in frailty. Given the rapid aging of the population, the association between frailty and age, and the impact of frailty on adverse outcomes for older adults, frailty is increasingly recognized as a significant public health concern. Early detection of the condition is critical for assisting older adults in regaining function and avoiding the negative consequences associated with the syndrome. Despite the critical nature of frailty diagnosis, there is no conclusive evidence or consensus regarding whether routine screening should be implemented. A variety of screening and assessment instruments have been developed from a biopsychosocial perspective, with frailty defined as a dynamic state caused by deficits in any of the physical, psychological, or social domains associated with health. All of these aspects of frailty should be identified and addressed through the use of a comprehensive and integrated approach to care. To accomplish this goal, public health and primary health care (PHC) must serve as the fulcrum around which care is delivered, not just to the elderly and frail, but to all individuals, by emphasizing a life-course and patient-centered approach centered on integrated, community-based care. Personnel in public health should be trained to address frailty not just clinically, but also in a societal context. Interventions should take place in the context of the individuals' environment and social networks. Additionally, public health professionals should contribute to community-based frailty education and training, promoting community-based interventions that assist older adults and their caregivers in preventing and managing frailty. The purpose of this paper is to provide an overview of frailty for a public health audience in order to increase awareness of the multidimensional nature of frailty and how it should be addressed through an integrated and holistic approach to care.

Questioning and prying into botulinum toxin after aesthetic treatment

Dr. Elghblawi reported a case of an allergy to Botox toxin A. that had arisen shortly after the injection, to be added to the existing literature. A 41-year-old Philippino lady experienced a severe localised reaction, with redness and nodular swelling on her face, after her second Botox injection. The lady did not have any prior medical illness. This case can help in assessment and appraisal of anticipated Botox allergies and raise awareness of the rare infrequent incident.