Antibiotic prophylaxis in caesarean section at Al-Helal Al-Emirati Hospital (Al-HEH), Gaza Strip, Palestine: A clinical audit

Background Nowadays, there is a general consensus among the current best guidelines about the procedural aspects of antibiotic prophylaxis in Caesarean Section (CS). Clinical audit, which has never been done before in the Gaza strip, is a tool of quality control used worldwide for healthcare improvement and is aimed at assessing clinicians’ and other clinical staffs’ adherence to the applicable guidelines. Objective This study was undertaken to audit the use of antibiotic prophylaxis in CS at Al-HEH, Gaza Strip, Palestine. Methods A sample of 38 cases was selected randomly among all the women who underwent CS during the period from 22 March 2015 to 16 April 2015. Using SPSS program, data were analysed for age, type of CS, whether they received antibiotics or not, type of antibiotics, and timing of its administration. Results Of the total 38 patients, urgent CS was carried out in 31.57% of cases while the procedure was elective in 68.42%. Antibiotic prophylaxis was given in 60.53% of cases before the surgery while no prophylaxis was received by the rest. Using Chi-Square Statistic, it was found that the correlation between the type of CS and the decision of prescribing antibiotics before the surgery to be statistically significant (P= 0.02). Moreover, 81.58% of cases were found to have received antibiotics after the surgery and a lack of uniformity of the antibiotics given to this group was also noted. Conclusion This study indicates that clinicians at Al-HEH do not follow evidence-based practice regarding antibiotic prophylaxis when managing CS patients. Moreover, the non-justified use of antibiotics again in many of those who received

Differences in rates and odds for emergency caesarean section in six Palestinian hospitals: A population-based birth cohort study

Objective To assess the differences in rates and odds for emergency caesarean section among singleton pregnancies in six governmental Palestinian hospitals. Design A prospective population-based birth cohort study. Setting Obstetric departments in six governmental Palestinian hospitals. Participants 32 321 women scheduled to deliver vaginally from 1 March 2015 until 29 February 2016. Methods To assess differences in sociodemographic and antenatal obstetric characteristics by hospital, χ2 test, analysis of variance and Kruskal-Wallis test were applied. Logistic regression was used to estimate differences in odds for emergency caesarean section, and ORs with 95% CIs were assessed. Main outcome measures The primary outcome was the adjusted ORs of emergency caesarean section among singleton pregnancies for five Palestinian hospitals as compared with the reference (Hospital 1). Results The prevalence of emergency caesarean section varied across hospitals, ranging from 5.8% to 22.6% among primiparous women and between 4.8% and 13.1% among parous women. Compared with the reference hospital, the ORs for emergency caesarean section were increased in all other hospitals, crude ORs ranging from 1.95 (95% CI 1.42 to 2.67) to 4.75 (95% CI 3.49 to 6.46) among primiparous women. For parous women, these differences were less pronounced, crude ORs ranging from 1.37 (95% CI 1.13 to 1.67) to 2.99 (95% CI 2.44 to 3.65). After adjustment for potential confounders, the ORs were reduced but still statistically significant, except for one hospital among parous women. Conclusion Substantial differences in odds for emergency caesarean section between the six Palestinian governmental hospitals were observed. These could not be explained by the studied sociodemographic or antenatal obstetric characteristics.publishedVersio

Management of Burns in Gaza-Strip A Multi-center Clinical Audit

A combined prospective and retrospective study was conducted in the ERs of Al-Shifa, Nasser Medical Complex and European Gaza hospitals. Two structured questionnaires were used to collect the management of burn according to the Palestinian management protocol. This study found that from the 147 cases that came to the ER, 37.6% underwent ABCDE approach and 87.8% (n=129/147) received sterile dressings. Background: Burns is a global public health problem and appropriate intervention will decrease morbidity and mortality. This study aimed to evaluate the management of burns in the emergency room (ER), burns units and intensive care units (ICU) of the Gaza-Strip. Objectives: To evaluate the management of burns in the ER, burns unit and ICU in terms of following ABCDE approach, using sterile dressings, giving fluid resuscitation, antibiotics, ranitidine and undergoing physiotherapy. Methods: A prospective study evaluated the management of patients presenting with burns injuries to the ER between the period 22nd July to 20 August 2018, and retrospectively, management of patients was evaluated, who were admitted to the burns units and to ICU between 1st January 2017 and 30th July 2018 at Al-Shifa Hospital and Nasser Medical Complex. The Palestinian management protocol was used for evaluation. A total of 428 patients were identified to have burns injuries during the study period. Of these, 142 were excluded, 108 due to missing files and 34 files had poor documentation (no documentation of medication or assessments). Included were 147 patients admitted to ER, 122 on the burns unit and 17 on the ICU. Results: In the ER, 57.1% (n=84/147) of patients were male, with a mean age of 15.4±14.1. Of the 147 cases, 17.7% (n=26/147) were major burns, which included more than 10% total body surface area burned (TBSA). Of these, 37.6% underwent ABCDE approach and 87.8% (n=129/147) received sterile dressings. From the 122 patients admitted to the burns unit, 59.8% (n=73) were male with a mean age of 11.4±14.6 years. From these, 47.5% (n=58/122) underwent fluid resuscitation, 97.5% (n=119/122) received antibiotics, 17.2% (n=21/122) received ranitidine and 56.6% (n=69/122) underwent physiotherapy. Out of the 17 patients admitted to ICU, 76.5% (n=13/17) were male, with a mean age of 19.2±12.8 years. All of these patients received prophylactic antibiotics, 58.8% (n=10/17) had endotracheal intubation, 5.9% (n=1/17) underwent central venous pressure measurement (CVP), 23.5% (n=4/17) had ABG tested and 88.2% (n=15/17) kidney function tests (KFT), and 64.7% (n=11/17) received ranitidine. No patient had a chest X-Ray (CXR) or carbon monoxide (CO) level done. From the ICU patients, 17.6% (n=3/17) benefitted from physiotherapy, and 35.3% (n=6/17) Conclusion: The findings of this study demonstrate poor adherence to guidelines in some points, such as patients presenting with major burns, who should all benefit from the ABCDE approach, but less than 40% of patients actually did and antibiotics, which should only be prescribed when indicated, were given to nearly all patients admitted to the burns unit or ICU. Efforts are required to improve staff practices with burn injuries

Quality of Pain Relief Provided in the Emergency Room (ER) for Patients with Acute Abdominal Pain A Prospective Clinical Audit

A prospective study was conducted in the ERs of Al-Shifa, Indonesian and European Gaza hospitals, a structured questionnaire was used to collect characteristics of pain and its management. Pain intensity was recorded at different intervals using a 10-point numerical rating scale. This study found that patients attended to ER with a mean pain score of 8.3±1.4 and they left with a mean pain score of 4.6±3.5. burns. Background: Acute abdominal pain is the most common cause of surgical consultations in the ER and the most common cause of non-trauma related admissions. Little is known about pain management in Gaza Strip hospitals. Therefore, this study assesses whether patients presenting with acute abdominal pain received adequate analgesia, compared to the Royal College of Emergency Medicine Guidelines. Objectives: To assess pain management in the ER in terms of the prescription practice of pain-relieving medications, pain progression from arrival till disposition and adequacy of analgesics provided. Methodology: A prospective-observational study was conducted in the ERs of three Gaza Strip hospitals, representing three distinct geographical areas, from 30th July till 30th August. All Patients above 18 years old, presented to the ER with acute abdominal pain, with no history of analgesia intake before their hospital visit were included. Data was collected by nine trained interviewers through a structured questionnaire. Pain was quantified by the patients by a 10-point numerical rating scale. This was done on arrival as well as at 30 and 60 minutes after receipt of analgesia and at discharge. Verbal consent was obtained from the patients. Approval had been obtained from the Directorate General of Human Resources Development before data collection. Data were analyzed via SPSS and are presented as mean scores ± standard deviations as well as in total numbers and percentages. Results: A total of 157 patients were included, 77 (49%) were males and the mean age was 39.8+15.4 years. Furthermore, 78 (49.7%) were from Hospital A, 52 (33.1%) from Hospital B and 27 (17.2%) from Hospital C. The sample included 100 (63.7%) patients with a provisional diagnosis of renal colic, 17 (10.8%) with biliary colic, 13 (8.3%) with appendicitis, 9 (5.7%) with intestinal obstruction and 18 (11.4%) other diagnoses. A total of 29 patients (18.5%) did not receive any analgesia in the ER. Of the 128 patients (81.5%), who received analgesics, 115 (89.8%) had non-steroidals while 13 (10.1%) received opioids. Opioids were adequately titrated in all patients and no circulatory instability occurred. The mean pain score on arrival was 8.3±1.4, while it was 7.1±3.6 30 minutes later, 6.6±4.2 after 60 minutes and 4.6±3.5 on discharge. Conclusion: Although pain relief was given and experienced pain decreased for most patients, but only seven patients (4.4%) were completely pain-free on discharge. Generally, patients with intense pain were quickly given analgesics. Hence, efforts should be focused on patients suffering moderate or mild pain to also receive adequate pain relief in the ER. Agreed local guidelines and training of staff could also facilitate this process

Modular architecture of eukaryotic RNase P and RNase MRP revealed by electron microscopy

Ribonuclease P (RNase P) and RNase MRP are closely related ribonucleoprotein enzymes, which process RNA substrates including tRNA precursors for RNase P and 5.8 S rRNA precursors, as well as some mRNAs, for RNase MRP. The structures of RNase P and RNase MRP have not yet been solved, so it is unclear how the proteins contribute to the structure of the complexes and how substrate specificity is determined. Using electron microscopy and image processing we show that eukaryotic RNase P and RNase MRP have a modular architecture, where proteins stabilize the RNA fold and contribute to cavities, channels and chambers between the modules. Such features are located at strategic positions for substrate recognition by shape and coordination of the cleaved-off sequence. These are also the sites of greatest difference between RNase P and RNase MRP, highlighting the importance of the adaptation of this region to the different substrates

Assessing Barriers to and Level of Adherence to Hypertension Therapy among Palestinians Living in the Gaza Strip: A Chance for Policy Innovation

Introduction. Hypertension is a major health concern, especially in low-income countries. Nonadherence and poor or no persistence in adhering to hypertension treatment regimens result in uncontrolled high blood pressure, increasing rates of mortality and morbidity, and preventable healthcare costs. The aim of this study was to assess the level of adherence and barriers to treatment regimens among hypertensive patients living in the Gaza Strip, Palestine. Methods. A convenience sample of 648 participants completed the Hill-Bone Compliance to High Blood Pressure Therapy Scale. The great majority of participants (n = 521, 80.4%) was highly adherent to their treatment regimen, 123 participants (18.98%) were classified as moderately nonadherent, and 4 (0.62%) participants were classified as highly nonadherent to their hypertension treatment regimen. Participants of this study showed the highest adherence rate to the domain of medication adherence (mean of 1.42 out of 4) followed by appointment keeping (mean 1.8), while they were least adherent to diet (mean of 2.18). The greatest three barriers to adherence to the recommended treatment regimen reported by participants were inability to exercise, inability to resist fast and fried food, and inability to keep themselves away from salty foods. Conclusion. Overall adherence to medication in Gaza was surprisingly good in patients with a diagnosis of hypertension for at least one year. However, adherence to lifestyle advice or dietary regimes remains poor. A combination of interventions using low-cost mobile technology, combined with face-to-face interventions by healthcare professionals, can be applied to improve adherence to hypertension treatment regimens in order to reduce the consequences of uncontrolled blood pressure

Exploring the impact of indication on variation in rates of intrapartum caesarean section in six Palestinian hospitals: a prospective cohort study

Abstract Background Caesarean section rates are rising globally. No specific caesarian section rate at either country-level or hospital-level was recommended. In Palestinian government hospitals, nearly one-fourth of all births were caesarean sections, ranging from 14.5 to 35.6%. Our aim was to assess whether variation in odds for intrapartum caesarean section in six Palestinian government hospitals can be explained by differences in indications. Methods Data on maternal and fetal health were collected prospectively for all women scheduled for vaginal delivery during the period from 1st March 2015 to 30th November 2016 in six government hospitals in Palestine. Comparisons of proportions in sociodemographic, antenatal obstetric characteristics and indications by the hospital were tested by χ2 test and differences in means by one-way ANOVA analysis. The odds for intrapartum caesarean section were estimated by logistic regression. The amount of explained variance was estimated by Nagelkerke R square. Results Out of 51,041 women, 4724 (9.3%) underwent intrapartum caesarean section. The prevalence of intrapartum caesarean section varied across hospitals; from 7.6 to 22.1% in nulliparous, and from 5.8 to 14.1% among parous women. The most common indications were fetal distress and failure to progress in nulliparous, and previous caesarean section with an additional obstetric indication among parous women. Adjusted ORs for intrapartum caesarean section among nulliparous women ranged from 0.42 (95% CI 0.31 to 0.57) to 2.41 (95% CI 1.70 to 3.40) compared to the reference hospital, and from 0.50 (95% CI 0.40–0.63) to 2.07 (95% CI 1.61 to 2.67) among parous women. Indications explained 58 and 66% of the variation in intrapartum caesarean section among nulliparous and parous women, respectively. Conclusion The differences in odds for intrapartum caesarean section among hospitals could not be fully explained by differences in indications. Further investigations on provider related factors as well as maternal and fetal outcomes in different hospitals are necessary