Implementation of Palliative Care in Palestine: Cultural and Religious Perspectives

The care of terminally ill cancer patients poses a significant global public health problem.1 Populations are growing older as healthcare interventions become increasingly more effective in the management of chronic diseases.2 Care of the terminally ill patients has evolved significantly over the centuries in the developed countries from Hospice services to highly specialized palliative care programs and facilities. In the Middle East, the progress in this area has been very slow over the last two decades which could be attributed to several reasons including the lack of education, training, budgets and several other barriers.3 Although age projection for Palestinians does not indicate generational transition toward an older population,4 yet the increasing incidence of cancer cases and other chronic diseases that need palliation, alerts the policy makers to the crucial need of introducing and developing palliative care services. Thus, the aim of this paper is to: 1) Reflect on the need and access of the Palestinians living in the West Bank and Gaza Strip to palliative care; 2) Define the factors that might interfere with the proper introduction of palliative care; and 3) Focus on the positive compensatory effect of religion and culture on palliative care. The Palestinian population in the West Bank and Gaza Strip at the end of 2016 was 4.88 million (61% and 39%, respectively.4 Palestinians live in refugee camps were about 41.9% distributed between the West Bank and Gaza strip, and 16.7% live in rural areas (2.7% in Gaza Strip compared to 25.6% in the West Bank.4 The Palestinian population is a young generation, though it has been gradually aging; birth, fertility, and death rates have been dropping. In fact, the median age of the Palestinians was 16.4 years in 2000 and increased to 20 years in 2016, with 39.1% of the population under 15 years old compared to 2.9% over 65 years of age. The life expectancy of the population was 73.7 years in 2016 compared to 72.4 years in 2011.4,5 The Palestinian population has low income, and the majority do not have health insurance and cannot afford to seek medical care

Prevalence of tobacco use among young adults in Palestine

Background: Smoking tobacco is a worldwide public health issue. Over the last few decades, smoking patterns have been changing, reflected by increasing rates among young people and females in particular. Aims: This study aimed to determine the prevalence and modalities of smoking and to assess the factors, habits and beliefs that might encourage or discourage smoking among young adults in Palestine. Methods: A cross-sectional study was conducted in the West Bank in 2014 among Palestinians aged 18–25 years old. Subjects were recruited from six Palestinian universities (n=1997). Participants were asked to complete a questionnaire focusing on sociodemographics, knowledge and beliefs towards tobacco smoking, and the reasons that motivate or hinder smokers to quit. Results: The prevalence of tobacco smoking was found to be 47.7%. Males had higher smoking rates, consumption levels, and initiated smoking at younger ages (74.4% started at ≤18 years old). Smoking cigarettes and waterpipe were the most common forms among both sexes. Smokers were also found to consume higher amounts of caffeinated drinks and fast food, showed lower scores towards anti-smoking beliefs, and reported significantly higher prevalence of smoking-related symptoms and diseases, primarily shortness of breath (20.5%) and cough (16.6%). The majority of smokers reported attempting and willingness to quit smoking. Health and financial costs were the strongest factors encouraging quitting while mood changes and lack of self-control were the most reported discouraging factors. Moreover, smoking among family members and peers increased the odds of smoking. Conclusions: Increasing rates of smoking among young Palestinians and a growing popularity of waterpipe use should alert stakeholders to the necessity for the implementation of smoking prevention and awareness policies and programmes.Acknowledgements The authors thank the 1st year medical students at Al-Quds University, Palestine. Funding: None

Identification and management of Lynch syndrome in the Middle East and North African countries: outcome of a survey in 12 countries

BackgroundLynch syndrome (LS), the most common inherited form of colorectal cancer (CRC), is responsible for 3% of all cases of CRC. LS is caused by a mismatch repair gene defect and is characterized by a high risk for CRC, endometrial cancer and several other cancers. Identification of LS is of utmost importance because colonoscopic surveillance substantially improves a patient’s prognosis. Recently, a network of physicians in Middle Eastern and North African (ME/NA) countries was established to improve the identification and management of LS families. The aim of the present survey was to evaluate current healthcare for families with LS in this region.MethodsA questionnaire was developed that addressed the following issues: availability of clinical management guidelines for LS; attention paid to family history of cancer; availability of genetic services for identification and diagnosis of LS; and assessment of knowledge of LS surveillance. Members of the network and authors of recent papers on LS from ME/NA and neighbouring countries were invited to participate in the survey and complete the online questionnaire.ResultsA total of 55 individuals were invited and 19 respondents from twelve countries including Algeria, Azerbaijan, Cyprus, Egypt, Iran, Jordan, Kuwait, Lebanon, Morocco, Palestine, Tunisia, and Turkey completed the questionnaire. The results showed that family history of CRC is considered in less than half of the surveyed countries. Guidelines for the man-agement of LS are available in three out of twelve countries. The identification and selection of families for genetic testing were based on clinical criteria (Amsterdam criteria II or Revised Bethesda criteria) in most countries, and only one country performed universal screening. In most of the surveyed countries genetic services were available in few hospitals or only in a research setting. However, surveillance of LS families was offered in the majority of countries and most frequently consisted of regular colonoscopy.ConclusionThe identification and management of LS in ME/NA countries are suboptimal and as a result most LS families in the region remain undetected. Future efforts should focus on increasing awareness of LS amongst both the general popula-tion and doctors, and on the improvement of the infrastructure in these countries

Molecular Characterization of Methicillin Resistant Staphylococcus aureus in West Bank-Palestine

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a public health threat and a major cause of hospital-acquired and community-acquired infections. This study aimed to investigate the genetic diversity of MRSA isolates from 2015 to 2017 and to characterize the major MRSA clones and anti-biogram trends in Palestine. Methodology: Isolates were obtained from 112 patients admitted to different hospitals of West Bank and East Jerusalem, originating from different clinical sources. Antibiotic susceptibility patterns, staphylococcal chromosomal cassette mec (SCCmec) typing, and Staphylococcus aureus protein A (spa) typing were determined. Also, a panel of toxin genes and virulence factors was studied, including: Panton-Valentine Leukocidin (PVL), ACME-arcA, Toxic Shock Syndrome Toxin-1 (TSST-1), and Exfoliative Toxin A (ETA). Results: Of the 112 confirmed MRSA isolates, 100% were resistant to all β-lactam antibiotics. Resistance rates to other non- β-lactam classes were as the following: 18.8% were resistant to trimethoprim-sulfamethoxazole, 23.2% were resistant to gentamicin, 34.8% to clindamycin, 39.3% to ciprofloxacin, and 63.4% to erythromycin. All MRSA isolates were susceptible to vancomycin (100%). Of all isolates, 32 isolates (28.6%) were multidrug- resistant (MDR). The majority of the isolates were identified as SCCmec type IV (86.6%). The molecular typing identified 29 spa types representing 12 MLST-clonal complexes (CC). The most prevalent spa types were: spa type t386 (CC1)/(12.5%), spa type t044 (CC80)/(10.7%), spa type t008 (CC8)/(10.7%), and spa type t223 (CC22)/(9.8%). PVL toxin gene was detected in (29.5%) of all isolates, while ACME-arcA gene was present in 18.8% of all isolates and 23.2% had the TSST-1 gene. The two most common spa types among the TSST-1positive isolates were the spa type t223 (CC22)/(Gaza clone) and the spa type t021 (CC30)/(South West Pacific clone). All isolates with the spa type t991 were ETA positive (5.4%). USA-300 clone (spa type t008, positive for PVL toxin gene and ACME-arcA genes) was found in nine isolates (8.0%). Conclusions: Our results provide insights into the epidemiology of MRSA strains in Palestine. We report a high diversity of MRSA strains among hospitals in Palestine, with frequent SCCmec type IV carriage. The four prominent clones detected were: t386-IV/ CC1, the European clone (t044/CC80), Gaza clone (t223/CC22), and the USA-300 clone (t008/CC8).We greatly acknowledge all hospitals that provided us with the isolates and responded to our contact. Special thanks to Al- Makassed Islamic Charitable Hospital/microbiology laboratory in East Jerusalem; including; Mr. Sabri Baragthithi and Mrs. Suzan Idkaidek. Also, many thanks to Mr. Mamoun Obeideia from the Palestine Medical complex and Mrs. Namir Sabri from the Red Crescent Society in Jerusalem. Many special thanks to Dr. G. Regev-Yochay and Asaf Biber from Sheba Medical Center, assistance. This data were presented as partial requirements for a master degree of Microbiology and Immunology/Al-Quds University under supervision of KA

Study of Frequency and Characteristics of Red Blood Cell Alloimmunization in Thalassemic Patients: Multicenter Study from Palestine

Background. - alassemia is a common inherited hemolytic disorder in Palestine. Red blood cell (RBC) transfusion is the principal treatment but it may cause RBC alloimmunization. is study was conducted to determine the prevalence and characteristics of RBC alloimmunization among thalassemic patients in northern governorates of Palestine. Methods. A prospective multicenter observational study was conducted in the thalassemia transfusion centers in the northern governorates of Palestine. e study included 215 thalassemia patients who received regular blood transfusions. Clinical and transfusion records of patients were examined. Antibody screening and identi cation was conducted using the microcolum gel technique. Results. Two hundred een patients were included in the study. More than half (52.1%) of the patients were males. e median age of patients was 18 years (range: 12–24 years). e most frequent blood group was A (40.5%). Alloantibodies were detected in 12.6% of patients. Anti-D (33.3%), anti-K (25.9%) and anti-E (14.8%) were the most commonly isolated antibodies. ere was no association between age, sex, starting age of transfusion, number of transfused units, history of splenectomy and alloimmunization. Conclusions. Anti-Rh and anti-K antibodies were common among this cohort of patients. Age, sex, starting age of transfusion, number of transfused units, and history of splenectomy could not predict the occurrence of alloimmunization

Hemolytic Disease of the Fetus and New-born and Intrauterine Blood Transfusion among Palestinian Pregnant Women

Background: Intrauterine transfusion (IUT) is considered to be the most successful relief of fetal anemia resulting from Hemolytic Disease of Fetus and New-born (HDFN). This study aims to determine the frequencies of RBC alloantibodies that might cause fetal hemolysis and evaluate the perinatal outcome of IUTs in Palestine. Materials and Methods: We conducted a retrospective-cohort study of pregnant women who requited IUT procedure at Al-Makassed Hospital in East Jerusalem. We reviewed Blood-Bank records between 2003 and 2013. Data were collected on all RBC-alloimmunized pregnancies requiring IUTs including the age of pregnant women, blood typing, antibody identification, and antibody titers. Also, we collected clinical data from the patients' files about the obstetric history and current pregnancy. Results: A total of 222 IUTs were performed during the study period in 65 alloimmunized pregnancies. Of all cases, 95.4% were associated with anti-D, 36.9 % with anti-C, and 10.8% with anti-E. Other non-Rh antibodies included mainly Kell, Kidd (10.8%), Luth and Lewis. The median number of transfusions needed per pregnancy was 3. The survival rate in the study was 90% and 27.3% of cases were hydropic; survival rate was significantly higher for fetuses without hydropic fetalis. Conclusions: IUT can improve perinatal outcome in alloimmunized pregnancies. In Palestine, policies should be drawn to introduce this procedure to more Palestinian Hospitals to increase its accessibility to the patients. In addition, secondary prevention of anti-D associated sensitization by rhesus immune globulin to reduce the incidence of HDFN should be more efficaciously implemented.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors

Presence of autoimmune disease affects not only risk but also survival in patients with B‐cell non‐Hodgkin lymphoma

Although autoimmune diseases (AIDs) are known to predispose to non‐Hodgkin lymphoma (NHL), their association with NHL prognosis has rarely been investigated. We examined associations between autoimmunity and B‐cell NHL onset by comparing AID history (determined by self‐report and medication review and supplemented by chart review where possible) among 435 adult B‐NHL patients in Hadassah‐Hebrew University Medical Center, diagnosed 2009‐2014, and 414 age‐and‐sex frequency‐matched controls. We examined AIDs as a whole, B‐ and T‐cell–mediated AIDs, and autoimmune thyroid diseases. Among cases, we used Kaplan‐Meier and Cox regression models to assess the association of AID with overall survival and relapse‐free survival, adjusting for prognostically important patient and disease characteristics such as Ki67% staining, International Prognostic Index, rituximab treatment, and histological subgroup. Autoimmune diseases were associated with B‐NHL (odds ratio [OR] = 1.95; 95% confidence interval (CI), 1.31‐2.92), especially AIDs mediated by B‐cell activation (OR = 5.20; CI, 1.90‐14.3), which were particularly associated with marginal zone lymphoma (OR = 19.3; CI, 4.59‐80.9). We found that time to relapse for all B‐NHL patients with AIDs was significantly shorter (mean of 49.21 mo [±3.22]) than among patients without AID (mean of 59.74 mo [±1.62]), adjusted hazard ratio [HRadj] = 1.69 (CI, 1.03‐2.79). Specifically, in patients with diffuse large B‐cell lymphoma, of whom 91.8% had received rituximab, a history of B‐cell–mediated AIDs was associated with shorter relapse‐free survival and overall survival, HRadj = 8.34 (CI, 3.01‐ 23.1) and HRadj = 3.83 (CI, 1.20‐12.3), respectively. Beyond confirming the well‐known association between AIDs and B‐NHL, we found that AID is an adverse prognostic factor in B‐cell lymphoma, associated with a shortened time to relapse, suggesting that there are specific therapeutic challenges in the subgroup of patients suffering from both these diseases. Further work is required to address mechanisms of resistance to standard treatment in the setting of AID‐associated B‐NHL. In the era of immunotherapy, these findings have particular relevance.This study was made possible by the generous support of the American people through the United States Agency for International Development (USAID)/MERC grant no. TA‐MOU‐11‐M31‐025. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States Government; Israel Science Foundation (ISF) grant no. 877/10; and the Hadassah University Hospital Compensatory Fund. We thank Noemie Cohen for data entry

Acute Respiratory Tract Infections among HospitalizedPalestinian Patients (2011–2016): A Retrospective Study

Respiratory tract infections (RTIs) are a major public health concern. (is study aims to investigate the profiles and epide-miological characteristics of acute RTIs and respiratory pathogens in Palestinian hospitalized patients. Clinical samples fromhospitalized patients with symptoms of acute RTIs admitted between January 2011 and December 2016 were referred to thePalestinian Central Public Health Laboratory (PHCL) to identify the causative pathogen. Patients’ demographic information andthe results of the molecular identification were retrieved from the electronic database at the PHCL. A total of 15413 patients withacute RTIs were hospitalized during the study period. (e causal agent was identified only in 28.7% of the patients. Overall,influenza viruses were the most common cause of RTIs among hospitalized Palestinian patients in the West Bank. Children andelderlies were the most affected with RTIs. (e elderly population (≥60 years old) had the highest rates. After influenza A virus,respiratory syncytial virus (RSV), andBordetella pertussis(B. pertussis) were the most common causes of acute RTIs amonghospitalized Palestinian patients. Children showed the highest hospitalization rates for RSV,B. pertussis,adenovirus, enterovirus,andStreptococcus pneumoniae.On the other hand, elderlies had the highest rates of influenza. Outbreaks of RTIs occurred mainlyduring winter (between December and March). (e resurgence ofB. pertussisin spite of vaccination is alarming and requiresfurther investigation

Holistic Assessment of Community Palliative Care Needs Among Palestinian Cancer Patients

Background: Palliative care focuses on improving the quality of life of terminally ill patients and their families. Objectives: This cross-sectional study aims to assess the level of community palliative care among terminally ill Palestinian cancer patients and the needs of their families in the West-Bank and Gaza strip. Methodology: A cross-sectional survey was conducted among cancer patients. Patients were recruited through five hospitals that provide cancer care in the West Bank and Gaza Strip (Al-Hussein Hospital, Beit Jala; Augusta Victoria Hospital, Jerusalem; Istishari Arab Hospital, Ramallah; European Hospital and Abd Al-Aziz Al-Rantisi Hospital; Gaza). Data were collected using an interview-based questionnaire. The questionnaire focused on assessment of physical, psychosocial, emotional, and spiritual components of palliative care. In addition, the questionnaire assessed caregiver’s needs. Results: A total of 238 patients were interviewed. The mean age of the participants was 53.8±15 years. The most common types of cancer among patients were breast cancer (51 [21.4%]) and colorectal cancer (33 [13.9%]). Fifty percent of the patients had their children as their primary caregivers. Overall, the majority of the patients had good psychosocial, spiritual, and emotional scores. On the other hand, >80% had moderate to poor physical functioning scores. Psychosocial and emotional scores decreased significantly as the disease progressed. More than 33% of the patients reported that their caregivers were in need of financial, legal, and work-related support. In addition, other commonly reported unmet needs included support in understanding what to expect in the future and dealing with the feelings and worries of the patient. Conclusions: Cancer patients suffer mostly from their physical symptoms in addition to financial problems. On the other hand, assessment of the emotional, spiritual and psychological functioning of Palestinian patients indicates that the strength of religious beliefs and the support of the family and the friends in the Palestinian community had a great impact on the patients and help reduced the gap in palliative care services

Molecular Characterization of Methicillin Resistant Staphylococcus aureus in West Bank-Palestine

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a public health threat and a major cause of hospital-acquired and community-acquired infections. This study aimed to investigate the genetic diversity of MRSA isolates from 2015 to 2017 and to characterize the major MRSA clones and anti-biogram trends in Palestine.Methodology: Isolates were obtained from 112 patients admitted to different hospitals of West Bank and East Jerusalem, originating from different clinical sources. Antibiotic susceptibility patterns, staphylococcal chromosomal cassette mec (SCCmec) typing, and Staphylococcus aureus protein A (spa) typing were determined. Also, a panel of toxin genes and virulence factors was studied, including: Panton-Valentine Leukocidin (PVL), ACME-arcA, Toxic Shock Syndrome Toxin-1 (TSST-1), and Exfoliative Toxin A (ETA).Results: Of the 112 confirmed MRSA isolates, 100% were resistant to all β-lactam antibiotics. Resistance rates to other non- β-lactam classes were as the following: 18.8% were resistant to trimethoprim-sulfamethoxazole, 23.2% were resistant to gentamicin, 34.8% to clindamycin, 39.3% to ciprofloxacin, and 63.4% to erythromycin. All MRSA isolates were susceptible to vancomycin (100%). Of all isolates, 32 isolates (28.6%) were multidrug- resistant (MDR). The majority of the isolates were identified as SCCmec type IV (86.6%). The molecular typing identified 29 spa types representing 12 MLST-clonal complexes (CC). The most prevalent spa types were: spa type t386 (CC1)/(12.5%), spa type t044 (CC80)/(10.7%), spa type t008 (CC8)/(10.7%), and spa type t223 (CC22)/(9.8%). PVL toxin gene was detected in (29.5%) of all isolates, while ACME-arcA gene was present in 18.8% of all isolates and 23.2% had the TSST-1 gene. The two most common spa types among the TSST-1positive isolates were the spa type t223 (CC22)/(Gaza clone) and the spa type t021 (CC30)/(South West Pacific clone). All isolates with the spa type t991 were ETA positive (5.4%). USA-300 clone (spa type t008, positive for PVL toxin gene and ACME-arcA genes) was found in nine isolates (8.0%).Conclusions: Our results provide insights into the epidemiology of MRSA strains in Palestine. We report a high diversity of MRSA strains among hospitals in Palestine, with frequent SCCmec type IV carriage. The four prominent clones detected were: t386-IV/ CC1, the European clone (t044/CC80), Gaza clone (t223/CC22), and the USA-300 clone (t008/CC8)